Nutrition
November 16 2009
Comments
Low vitamin D levels are very likely limiting your running performance, and may compromise your health.
Written by: Reyana Ewing, MPH, RD, CLE
As runners we want to do everything possible to perform well and have a great season. We are meticulous about our training schedules, hydration, sleeping habits, etc. Yet many times we fall short when it comes to nutrition.
My Story
In the summer of 2008 I started to feel rather lethargic during workouts and I struggled to maintain my normal training paces. My recovery from my harder efforts and long runs took longer than usual. I immediately and incorrectly assumed I had low serum ferritin levels indicating iron deficiency anemia.
One colleague to whom I lamented about my chronic fatigue asked me if I had checked my vitamin D levels. “Vitamin D levels?” I exclaimed. I live in California, it is summer, and I am outside way more than the recommended 20 to 30 minutes a day. There is no way I could be vitamin D deficient, especially since in addition to being exposed to sun most days, I eat a very balanced diet that includes a daily multivitamin supplement. However, a visit to my doctor confirmed that my serum 25–hydroxy-vitamin D (25(OH)D) value was dangerously low (18 ng/ml). Normal levels are between 40-70 ng/ml. And for those with chronic diseases such as cancer, heart disease, diabetes, and multiple sclerosis, normal blood levels should be between 55-70 ng/ml. I was shocked.
I immediately started daily supplementation with 1000 IU of vitamin D (Vitamin D3). After 8 weeks, my 25(OH)D level had improved somewhat (28 ng/ml). I did feel slightly better, but I wanted to recover completely, so I upped my dosage to 2000 IU daily. A few weeks later my levels were within the normal range (56 ng/ml). I felt noticeably stronger and was able to hit my usual paces during training. And in October 2008, I set a half marathon personal record.
Deficiency
This was my very first experience with vitamin D deficiency and I have since learned that vitamin D deficiency is becoming an epidemic worldwide, not only in geographic regions where sun exposure is limited. And my discussions with fellow dietitians working with college runners and professional athletes in generally sunny states (Texas and Florida) confirmed the alarming prevalence of vitamin D deficiency across ethnicity and gender.
Athletes who live in northern latitudes (north of 35 degrees), or use sunscreen consistently, perform their sport indoors, or keep their skin covered are at the greatest risk. Melanin affects the production of vitamin D. So those with more melanin or darker skin produce less vitamin D. Since vitamin D is a fat-soluble vitamin, athletes with fat malabsorption problems such as cystic fibrosis, Crohn’s disease, and celiac disease are at risk for deficiency. Those who have normal levels typically (around 50 ng/ml) live in sub-equatorial Africa and work outdoors for most of the summer.
Once thought of as being primarily involved in bone development, activated vitamin D (calcitriol), a steroid hormone, is responsible for regulating more than 1000 human genes. Almost every cell in the human body has receptors for vitamin D. Recent research shows that vitamin D deficiency increases the risk of different types of cancer (such as breast cancer and prostate cancer), as well as heart disease, diabetes, depression, autoimmune diseases, hypertension, obesity, gum disease, chronic pain, muscle wasting, inflammation, birth defects, osteoporosis, influenza and colds, etc.
Importance for Endurance Athletes
We are only just beginning to understand the complexity and importance of vitamin D in relation to health. Of importance to athletes is the function of vitamin D as it relates to overall health, bone density, innate immunity, muscle wasting, and exercise-related inflammation and immunity. To train and race optimally, an athlete should not have any nutrient deficiencies.
Bone Health:
Deena Kastor, Olympic Marathoner, broke her foot in Beijing during the 2008 Olympic Marathon. It was discovered that her calcium levels were normal, but her 25(OH)D levels were reported to be around 15 ng/ml. And Kastor lives in sunny California. Because of an early scare with skin cancer, she is known to apply sunscreen for all of her outdoor runs, thus limiting her ability to manufacture vitamin D from sun exposure. Even with the extensive research to show vitamin D and calcium’s role in preventing osteoporosis, elite, college, and high school athletes continue to be deficient in one or both nutrient(s). Stress fractures are quite prevalent in runners and yet so preventable.
Increased VO2 max:
German research studies dating back to the 1950s show that athletes exposed to vitamin D-producing ultraviolet light had improved athletic performance. Other studies showed that athletic performance peaked at the end of the summer. Peak performance was also associated with 25(OH)D levels around 50 ng/ml. In addition, maximal oxygen uptake was found to drop when less ultraviolet rays reached the earth, for example, in the late fall. This is particularly a problem for marathoners training through the summer for fall marathons.
Reduced Inflammation:
After intense exercise, endurance athletes experience inflammation due to elevated levels of pro-inflammatory cytokines. Vitamin D reduces the production of these cytokines while increasing the production of anti-inflammatory cytokines, thereby speeding the recovery process between hard workouts.
Improved Immunity:
In a February 2009 study published in the Archives of Internal Medicine, vitamin D3 levels were tested in 19, 000 Americans. Those with low levels of vitamin D had the highest incidence of colds and influenza. This is important information for endurance athletes who strive to balance heavy training loads and staying healthy.
What can be done?
Check 25(OH)D levels regularly and supplement as needed.
Check for total 25(OH)D and not 1, 25(OH)D, which will tell you nothing about your blood stores. Total 25(OH)D reflects all sources of vitamin D – from food, UV energy (photo-production), and supplementation.
Deficient athletes measuring less than 30 ng/ml should supplement with 20,000 IU to
50, 000 IU of vitamin D3 per week for 8 weeks andrecheck serum 25(OH)D until normal values are attained.
Get regular, safe, twice-daily (5-30 minutes) exposure to sun between the hours of 10 am and 3 pm. Note that sunscreen and glass (being indoors) reduce or block UV energy.
Supplement with 1000 IU to 2000 IU of vitamin D3 to maintain normal levels.
For those living or competing in northern latitudes (north of Atlanta, GA) little to no vitamin D production will occur, so consumption of fortified foods and supplements is a necessity.
Food Sources of vitamin D
There aren’t many naturally occurring foods that contain vitamin D. Most of the foods containing vitamin D have been fortified, for example milk and certain juices.
Table 1. Food Sources of Vitamin D FOOD Serving IU per serving *
Fish liver oils (cod liver oil) 1TBSP 1360
Herring, cooked 3 oz 1383
Wild salmon, cooked 3.5 oz 981
Farm salmon, cooked 3.5 oz 249
Tuna, canned in oil 3.5 oz 200
Milk, non fat, reduced fat, whole (fortified) 8 oz 100
Margarine, fortified 1 TBSP 60
Egg 1 whole 18
Beef, liver 3.5 oz 15
Cheese 1 oz 12
*IU = International Units
Dietary Supplement Fact Sheet. National Institute of Health (2007)
Caution
High intakes of vitamin D can cause nausea, vomiting, poor appetite, weakness, and constipation. Current safe upper limits are set at 2000 IU by the National Institute of Health, but there are newer data supporting upper limits as high as 10,000 IU per day.
***
Reyana Ewing. Photo courtesy: Fuel to Move.
Reyana Ewing, MPH, RD, CLE is a registered dietitian, sports dietitian and runner based in Santa Rosa, Calif. Find our more about her at www.fueltomove.com
Monday, November 16, 2009
Sunday, May 24, 2009
Brain Power - At the Bridge Table, Clues to a Lucid Old Age
May 22, 2009
By BENEDICT CAREY
LAGUNA WOODS, Calif. — The ladies in the card room are playing bridge, and at their age the game is no hobby. It is a way of life, a daily comfort and challenge, the last communal campfire before all goes dark.
“We play for blood,” says Ruth Cummins, 92, before taking a sip of Red Bull at a recent game.
“It’s what keeps us going,” adds Georgia Scott, 99. “It’s where our closest friends are.”
In recent years scientists have become intensely interested in what could be called a super memory club — the fewer than one in 200 of us who, like Ms. Scott and Ms. Cummins, have lived past 90 without a trace of dementia. It is a group that, for the first time, is large enough to provide a glimpse into the lucid brain at the furthest reach of human life, and to help researchers tease apart what, exactly, is essential in preserving mental sharpness to the end.
“These are the most successful agers on earth, and they’re only just beginning to teach us what’s important, in their genes, in their routines, in their lives,” said Dr. Claudia Kawas, a neurologist at the University of California, Irvine. “We think, for example, that it’s very important to use your brain, to keep challenging your mind, but all mental activities may not be equal. We’re seeing some evidence that a social component may be crucial.”
Laguna Woods, a sprawling retirement community of 20,000 south of Los Angeles, is at the center of the world’s largest decades-long study of health and mental acuity in the elderly. Begun by University of Southern California researchers in 1981 and called the 90+ Study, it has included more than 14,000 people aged 65 and older, and more than 1,000 aged 90 or older.
Such studies can take years to bear fruit, and the results of this study are starting to alter the way scientists understand the aging brain. The evidence suggests that people who spend long stretches of their days, three hours and more, engrossed in some mental activities like cards may be at reduced risk of developing dementia. Researchers are trying to tease apart cause from effect: Are they active because they are sharp, or sharp because they are active?
The researchers have also demonstrated that the percentage of people with dementia after 90 does not plateau or taper off, as some experts had suspected. It continues to increase, so that for the one in 600 people who make it to 95, nearly 40 percent of the men and 60 percent of the women qualify for a diagnosis of dementia.
At the same time, findings from this and other continuing studies of the very old have provided hints that some genes may help people remain lucid even with brains that show all the biological ravages of Alzheimer’s disease. In the 90+ Study here, now a joint project run by U.S.C. and the University of California, Irvine, researchers regularly run genetic tests, test residents’ memory, track their activities, take blood samples, and in some cases do postmortem analyses of their brains. Researchers at Irvine maintain a brain bank of more than 100 specimens.
To move into the gated village of Laguna Woods, a tidy array of bungalows and condominiums that blends easily into southern Orange County, people must meet several requirements, one of which is that they do not need full-time care. Their minds are sharp when they arrive, whether they are 65 or 95.
They begin a new life here. Make new friends. Perhaps connect with new romantic partners. Try new activities, at one of the community’s fitness centers; or new hobbies, in the more than 400 residents’ clubs. They are as busy as arriving freshmen at a new campus, with one large difference: they are less interested in the future, or in the past.
“We live for the day,” said Dr. Leon Manheimer, a longtime resident who is in his 90s.
Yet it is precisely that ability to form new memories of the day, the present, that usually goes first in dementia cases, studies in Laguna Woods and elsewhere have found.
The very old who live among their peers know this intimately, and have developed their own expertise, their own laboratory. They diagnose each other, based on careful observation. And they have learned to distinguish among different kinds of memory loss, which are manageable and which ominous.
A Seat at the Table
Here at Laguna Woods, many residents make such delicate calculations in one place: the bridge table.
Contract bridge requires a strong memory. It involves four players, paired off, and each player must read his or her partner’s strategy by closely following what is played. Good players remember every card played and its significance for the team. Forget a card, or fall behind, and it can cost the team — and the social connection — dearly.
“When a partner starts to slip, you can’t trust them,” said Julie Davis, 89, a regular player living in Laguna Woods. “That’s what it comes down to. It’s terrible to say it that way, and worse to watch it happen. But other players get very annoyed. You can’t help yourself.”
At the Friday afternoon bridge game, Ms. Cummins and Ms. Scott sit with two other players, both women in their 90s. Gossip flows freely between hands, about residents whose talk is bigger than their game, about a 100-year-old man who collapsed and died that week in an exercise class.
But the women are all business during play.
“What was that you played, a spade was it?” a partner asks Ms. Cummins.
“Yes, a spade,” says Ms. Cummins, with some irritation. “It was a spade.”
Later, the partner stares uncertainly at the cards on the table. “Is that ——”
“We played that trick already,” Ms. Cummins says. “You’re a trick behind.”
Most regular players at Laguna Woods know of at least one player who, embarrassed by lapses, bowed out of the regular game. “A friend of mine, a very good player, when she thought she couldn’t keep up, she automatically dropped out,” Ms. Cummins said. “That’s usually what happens.”
Yet it is part of the tragedy of dementia that, in many cases, the condition quickly robs people of self-awareness. They will not voluntarily abandon the one thing that, perhaps more than any other, defines their daily existence.
“And then it’s really tough,” Ms. Davis said. “I mean, what do you do? These are your friends.”
Staying in the Game
So far, scientists here have found little evidence that diet or exercise affects the risk of dementia in people over 90. But some researchers argue that mental engagement — doing crossword puzzles, reading books — may delay the arrival of symptoms. And social connections, including interaction with friends, may be very important, some suspect. In isolation, a healthy human mind can go blank and quickly become disoriented, psychologists have found.
“There is quite a bit of evidence now suggesting that the more people you have contact with, in your own home or outside, the better you do” mentally and physically, Dr. Kawas said. “Interacting with people regularly, even strangers, uses easily as much brain power as doing puzzles, and it wouldn’t surprise me if this is what it’s all about.”
And bridge, she added, provides both kinds of stimulation.
The unstated rule at Laguna Woods is to support a friend who is slipping, to act as a kind of memory supplement. “We’re all afraid to lose memory; we’re all at risk of that,” said one regular player in her 90s, who asked not to be named.
Woody Bowersock, 96, a former school principal, helped a teammate on a swim team at Laguna Woods to race even as dementia stole the man’s ability to form almost any new memory.
“You’d have to put him up on the platform just before the race, just walk him over there,” Mr. Bowersock said. “But if the whistle didn’t blow right away, he’d wander off. I tell you, I’d sometimes have to stand there with him until he was in the water. Then he was fine. A very good swimmer. Freestyle.”
Bridge is a different kind of challenge, but some residents here swear that the very good players can play by instinct even when their memory is dissolving.
“I know a man who’s 95, he is starting with dementia and plays bridge, and he forgets hands,” said Marilyn Ruekberg, who lives in Laguna Woods. “I bring him in as a partner anyway, and by the end we do exceedingly well. I don’t know how he does it, but he has lots of experience in the game.”
Scientists suspect that some people with deep experience in a game like bridge may be able to draw on reserves to buffer against memory lapses. But there is not enough evidence one way or the other to know.
Ms. Ruekberg said she cared less about that than about her friend: “I just want to give him something more during the day than his four walls.”
Drawing the Line
In studies of the very old, researchers in California, New York, Boston and elsewhere have found clues to that good fortune. For instance, Dr. Kawas’s group has found that some people who are lucid until the end of a very long life have brains that appear riddled with Alzheimer’s disease. In a study released last month, the researchers report that many of them carry a gene variant called APOE2, which may help them maintain mental sharpness.
Dr. Nir Barzilai of the Albert Einstein College of Medicine has found that lucid Ashkenazi Jewish centenarians are three times more likely to carry a gene called CETP, which appears to increase the size and amount of so-called good cholesterol particles, than peers who succumbed to dementia.
“We don’t know how this could be protective, but it’s very strongly correlated with good cognitive function at this late age,” Dr. Barzilai said. “And at least it gives us a target for future treatments.”
For those in the super-memory club, that future is too far off to be meaningful. What matters most is continued independence. And that means that, at some point, they have to let go of close friends.
“The first thing you always want to do is run and help them,” Ms. Davis said. “But after a while you end up asking yourself: ‘What is my role here? Am I now the caregiver?’ You have to decide how far you’ll go, when you have your own life to live.”
In this world, as in high school, it is all but impossible to take back an invitation to the party. Some players decide to break up their game, at least for a time, only to reform it with another player. Or, they might suggest that a player drop down a level, from a serious game to a more casual one. No player can stand to hear that. Every day in card rooms around the world, some of them will.
“You don’t play with them, period,” Ms. Cummins said. “You’re not cruel. You’re just busy.”
The rhythm of bidding and taking tricks, the easy conversation between hands, the daily game — after almost a century, even for the luckiest in the genetic lottery, it finally ends.
“People stop playing,” said Norma Koskoff, another regular player here, “and very often when they stop playing, they don’t live much longer.”
By BENEDICT CAREY
LAGUNA WOODS, Calif. — The ladies in the card room are playing bridge, and at their age the game is no hobby. It is a way of life, a daily comfort and challenge, the last communal campfire before all goes dark.
“We play for blood,” says Ruth Cummins, 92, before taking a sip of Red Bull at a recent game.
“It’s what keeps us going,” adds Georgia Scott, 99. “It’s where our closest friends are.”
In recent years scientists have become intensely interested in what could be called a super memory club — the fewer than one in 200 of us who, like Ms. Scott and Ms. Cummins, have lived past 90 without a trace of dementia. It is a group that, for the first time, is large enough to provide a glimpse into the lucid brain at the furthest reach of human life, and to help researchers tease apart what, exactly, is essential in preserving mental sharpness to the end.
“These are the most successful agers on earth, and they’re only just beginning to teach us what’s important, in their genes, in their routines, in their lives,” said Dr. Claudia Kawas, a neurologist at the University of California, Irvine. “We think, for example, that it’s very important to use your brain, to keep challenging your mind, but all mental activities may not be equal. We’re seeing some evidence that a social component may be crucial.”
Laguna Woods, a sprawling retirement community of 20,000 south of Los Angeles, is at the center of the world’s largest decades-long study of health and mental acuity in the elderly. Begun by University of Southern California researchers in 1981 and called the 90+ Study, it has included more than 14,000 people aged 65 and older, and more than 1,000 aged 90 or older.
Such studies can take years to bear fruit, and the results of this study are starting to alter the way scientists understand the aging brain. The evidence suggests that people who spend long stretches of their days, three hours and more, engrossed in some mental activities like cards may be at reduced risk of developing dementia. Researchers are trying to tease apart cause from effect: Are they active because they are sharp, or sharp because they are active?
The researchers have also demonstrated that the percentage of people with dementia after 90 does not plateau or taper off, as some experts had suspected. It continues to increase, so that for the one in 600 people who make it to 95, nearly 40 percent of the men and 60 percent of the women qualify for a diagnosis of dementia.
At the same time, findings from this and other continuing studies of the very old have provided hints that some genes may help people remain lucid even with brains that show all the biological ravages of Alzheimer’s disease. In the 90+ Study here, now a joint project run by U.S.C. and the University of California, Irvine, researchers regularly run genetic tests, test residents’ memory, track their activities, take blood samples, and in some cases do postmortem analyses of their brains. Researchers at Irvine maintain a brain bank of more than 100 specimens.
To move into the gated village of Laguna Woods, a tidy array of bungalows and condominiums that blends easily into southern Orange County, people must meet several requirements, one of which is that they do not need full-time care. Their minds are sharp when they arrive, whether they are 65 or 95.
They begin a new life here. Make new friends. Perhaps connect with new romantic partners. Try new activities, at one of the community’s fitness centers; or new hobbies, in the more than 400 residents’ clubs. They are as busy as arriving freshmen at a new campus, with one large difference: they are less interested in the future, or in the past.
“We live for the day,” said Dr. Leon Manheimer, a longtime resident who is in his 90s.
Yet it is precisely that ability to form new memories of the day, the present, that usually goes first in dementia cases, studies in Laguna Woods and elsewhere have found.
The very old who live among their peers know this intimately, and have developed their own expertise, their own laboratory. They diagnose each other, based on careful observation. And they have learned to distinguish among different kinds of memory loss, which are manageable and which ominous.
A Seat at the Table
Here at Laguna Woods, many residents make such delicate calculations in one place: the bridge table.
Contract bridge requires a strong memory. It involves four players, paired off, and each player must read his or her partner’s strategy by closely following what is played. Good players remember every card played and its significance for the team. Forget a card, or fall behind, and it can cost the team — and the social connection — dearly.
“When a partner starts to slip, you can’t trust them,” said Julie Davis, 89, a regular player living in Laguna Woods. “That’s what it comes down to. It’s terrible to say it that way, and worse to watch it happen. But other players get very annoyed. You can’t help yourself.”
At the Friday afternoon bridge game, Ms. Cummins and Ms. Scott sit with two other players, both women in their 90s. Gossip flows freely between hands, about residents whose talk is bigger than their game, about a 100-year-old man who collapsed and died that week in an exercise class.
But the women are all business during play.
“What was that you played, a spade was it?” a partner asks Ms. Cummins.
“Yes, a spade,” says Ms. Cummins, with some irritation. “It was a spade.”
Later, the partner stares uncertainly at the cards on the table. “Is that ——”
“We played that trick already,” Ms. Cummins says. “You’re a trick behind.”
Most regular players at Laguna Woods know of at least one player who, embarrassed by lapses, bowed out of the regular game. “A friend of mine, a very good player, when she thought she couldn’t keep up, she automatically dropped out,” Ms. Cummins said. “That’s usually what happens.”
Yet it is part of the tragedy of dementia that, in many cases, the condition quickly robs people of self-awareness. They will not voluntarily abandon the one thing that, perhaps more than any other, defines their daily existence.
“And then it’s really tough,” Ms. Davis said. “I mean, what do you do? These are your friends.”
Staying in the Game
So far, scientists here have found little evidence that diet or exercise affects the risk of dementia in people over 90. But some researchers argue that mental engagement — doing crossword puzzles, reading books — may delay the arrival of symptoms. And social connections, including interaction with friends, may be very important, some suspect. In isolation, a healthy human mind can go blank and quickly become disoriented, psychologists have found.
“There is quite a bit of evidence now suggesting that the more people you have contact with, in your own home or outside, the better you do” mentally and physically, Dr. Kawas said. “Interacting with people regularly, even strangers, uses easily as much brain power as doing puzzles, and it wouldn’t surprise me if this is what it’s all about.”
And bridge, she added, provides both kinds of stimulation.
The unstated rule at Laguna Woods is to support a friend who is slipping, to act as a kind of memory supplement. “We’re all afraid to lose memory; we’re all at risk of that,” said one regular player in her 90s, who asked not to be named.
Woody Bowersock, 96, a former school principal, helped a teammate on a swim team at Laguna Woods to race even as dementia stole the man’s ability to form almost any new memory.
“You’d have to put him up on the platform just before the race, just walk him over there,” Mr. Bowersock said. “But if the whistle didn’t blow right away, he’d wander off. I tell you, I’d sometimes have to stand there with him until he was in the water. Then he was fine. A very good swimmer. Freestyle.”
Bridge is a different kind of challenge, but some residents here swear that the very good players can play by instinct even when their memory is dissolving.
“I know a man who’s 95, he is starting with dementia and plays bridge, and he forgets hands,” said Marilyn Ruekberg, who lives in Laguna Woods. “I bring him in as a partner anyway, and by the end we do exceedingly well. I don’t know how he does it, but he has lots of experience in the game.”
Scientists suspect that some people with deep experience in a game like bridge may be able to draw on reserves to buffer against memory lapses. But there is not enough evidence one way or the other to know.
Ms. Ruekberg said she cared less about that than about her friend: “I just want to give him something more during the day than his four walls.”
Drawing the Line
In studies of the very old, researchers in California, New York, Boston and elsewhere have found clues to that good fortune. For instance, Dr. Kawas’s group has found that some people who are lucid until the end of a very long life have brains that appear riddled with Alzheimer’s disease. In a study released last month, the researchers report that many of them carry a gene variant called APOE2, which may help them maintain mental sharpness.
Dr. Nir Barzilai of the Albert Einstein College of Medicine has found that lucid Ashkenazi Jewish centenarians are three times more likely to carry a gene called CETP, which appears to increase the size and amount of so-called good cholesterol particles, than peers who succumbed to dementia.
“We don’t know how this could be protective, but it’s very strongly correlated with good cognitive function at this late age,” Dr. Barzilai said. “And at least it gives us a target for future treatments.”
For those in the super-memory club, that future is too far off to be meaningful. What matters most is continued independence. And that means that, at some point, they have to let go of close friends.
“The first thing you always want to do is run and help them,” Ms. Davis said. “But after a while you end up asking yourself: ‘What is my role here? Am I now the caregiver?’ You have to decide how far you’ll go, when you have your own life to live.”
In this world, as in high school, it is all but impossible to take back an invitation to the party. Some players decide to break up their game, at least for a time, only to reform it with another player. Or, they might suggest that a player drop down a level, from a serious game to a more casual one. No player can stand to hear that. Every day in card rooms around the world, some of them will.
“You don’t play with them, period,” Ms. Cummins said. “You’re not cruel. You’re just busy.”
The rhythm of bidding and taking tricks, the easy conversation between hands, the daily game — after almost a century, even for the luckiest in the genetic lottery, it finally ends.
“People stop playing,” said Norma Koskoff, another regular player here, “and very often when they stop playing, they don’t live much longer.”
Friday, April 3, 2009
CUTTING SALT ISN'T THE ONLY WAY TO REDUCE BLOOD PRESSURE
Study Suggests Boosting Potassium is also Effective
MAYWOOD, Ill. -- Most people know that too much sodium from foods can increase blood pressure.
A new study suggests that people trying to lower their blood pressure should also boost their intake of potassium, which has the opposite effect to sodium.
Researchers found that the ratio of sodium-to-potassium in subjects' urine was a much stronger predictor of cardiovascular disease than sodium or potassium alone.
"There isn't as much focus on potassium, but potassium seems to be effective in lowering blood pressure and the combination of a higher intake of potassium and lower consumption of sodium seems to be more effective than either on its own in reducing the risk of cardiovascular disease," said Dr. Paul Whelton, senior author of the study in the January 2009 issue of the Archives of Internal Medicine. Whelton is an epidemiologist and president and CEO of Loyola University Health System.
Researchers determined average sodium and potassium intake during two phases of a study known as the Trials of Hypertension Prevention. They collected 24-hour urine samples intermittently during an 18-month period in one trial and during a 36-month period in a second trial. The 2,974 study participants initially aged 30-to-54 and with blood pressure readings just under levels considered high, were followed for 10-15 years to see if they would develop cardiovascular disease. Whelton was national chair of the Trials of Hypertension Prevention.
Those with the highest sodium levels in their urine were 20 percent more likely to suffer strokes, heart attacks or other forms of cardiovascular disease compared with their counterparts with the lowest sodium levels. However this link was not strong enough to be considered statistically significant.
By contrast, participants with the highest sodium-to-potassium ratio in urine were 50 percent more likely to experience cardiovascular disease than those with the lowest sodium-to-potassium ratios. This link was statistically significant.
Most previous studies of the relationship between sodium or potassium and cardiovascular disease have had to rely on people's recall or record of what foods they eat to estimate their level of sodium consumption. This is a less precise measure of sodium intake than urine samples. In addition, many have been cross-sectional rather than follow-up studies.
The new study "is a quantum leap in the quality of the data compared to what we have had before," Whelton said.
Whelton was a member of a recent Institute of Medicine panel that set dietary recommendations for salt and potassium. The panel said healthy 19-to-50 year-old adults should consume no more than 2,300 milligrams of sodium per day -- equivalent to one teaspoon of table salt. More than 95 percent of American men and 75 percent of American women in this age range exceed this amount.
To lower blood pressure and blunt the effects of salt, adults should consume 4.7 grams of potassium per day unless they have a clinical condition or medication need that is a contraindication to increased potassium intake. Most American adults aged 31-to-50 consume only about half as much as recommended in the Institute of Medicine report. Changes in diet and physical activity should be under the supervision of a health care professional.
Good potassium sources include fruits, vegetables, dairy foods and fish. Foods that are especially rich in potassium include potatoes and sweet potatoes, fat-free milk and yogurt, tuna, lima beans, bananas, tomato sauce and orange juice. Potassium also is available in supplements.
Whelton is among the nation's top experts on high blood pressure. He has published more than 400 papers on the subject, and has been the principal investigator on more than $100 million of studies funded by the National Institutes of Health.
Co-authors of the Archives study include Nancy Cook (first author), Julie Buring and Dr. Kathryn Rexrode of Brigham and Women's Hospital; Eva Obarzanek and Dr. Jeffrey Cutler of the National Heart, Lung and Blood Institute; Dr. Lawrence Appel of Johns Hopkins University and Shiriki Kumanyika of the University of Pennsylvania.
###
MAYWOOD, Ill. -- Most people know that too much sodium from foods can increase blood pressure.
A new study suggests that people trying to lower their blood pressure should also boost their intake of potassium, which has the opposite effect to sodium.
Researchers found that the ratio of sodium-to-potassium in subjects' urine was a much stronger predictor of cardiovascular disease than sodium or potassium alone.
"There isn't as much focus on potassium, but potassium seems to be effective in lowering blood pressure and the combination of a higher intake of potassium and lower consumption of sodium seems to be more effective than either on its own in reducing the risk of cardiovascular disease," said Dr. Paul Whelton, senior author of the study in the January 2009 issue of the Archives of Internal Medicine. Whelton is an epidemiologist and president and CEO of Loyola University Health System.
Researchers determined average sodium and potassium intake during two phases of a study known as the Trials of Hypertension Prevention. They collected 24-hour urine samples intermittently during an 18-month period in one trial and during a 36-month period in a second trial. The 2,974 study participants initially aged 30-to-54 and with blood pressure readings just under levels considered high, were followed for 10-15 years to see if they would develop cardiovascular disease. Whelton was national chair of the Trials of Hypertension Prevention.
Those with the highest sodium levels in their urine were 20 percent more likely to suffer strokes, heart attacks or other forms of cardiovascular disease compared with their counterparts with the lowest sodium levels. However this link was not strong enough to be considered statistically significant.
By contrast, participants with the highest sodium-to-potassium ratio in urine were 50 percent more likely to experience cardiovascular disease than those with the lowest sodium-to-potassium ratios. This link was statistically significant.
Most previous studies of the relationship between sodium or potassium and cardiovascular disease have had to rely on people's recall or record of what foods they eat to estimate their level of sodium consumption. This is a less precise measure of sodium intake than urine samples. In addition, many have been cross-sectional rather than follow-up studies.
The new study "is a quantum leap in the quality of the data compared to what we have had before," Whelton said.
Whelton was a member of a recent Institute of Medicine panel that set dietary recommendations for salt and potassium. The panel said healthy 19-to-50 year-old adults should consume no more than 2,300 milligrams of sodium per day -- equivalent to one teaspoon of table salt. More than 95 percent of American men and 75 percent of American women in this age range exceed this amount.
To lower blood pressure and blunt the effects of salt, adults should consume 4.7 grams of potassium per day unless they have a clinical condition or medication need that is a contraindication to increased potassium intake. Most American adults aged 31-to-50 consume only about half as much as recommended in the Institute of Medicine report. Changes in diet and physical activity should be under the supervision of a health care professional.
Good potassium sources include fruits, vegetables, dairy foods and fish. Foods that are especially rich in potassium include potatoes and sweet potatoes, fat-free milk and yogurt, tuna, lima beans, bananas, tomato sauce and orange juice. Potassium also is available in supplements.
Whelton is among the nation's top experts on high blood pressure. He has published more than 400 papers on the subject, and has been the principal investigator on more than $100 million of studies funded by the National Institutes of Health.
Co-authors of the Archives study include Nancy Cook (first author), Julie Buring and Dr. Kathryn Rexrode of Brigham and Women's Hospital; Eva Obarzanek and Dr. Jeffrey Cutler of the National Heart, Lung and Blood Institute; Dr. Lawrence Appel of Johns Hopkins University and Shiriki Kumanyika of the University of Pennsylvania.
###
Based in the western suburbs of Chicago, Loyola University Health System is a quaternary care system with a 61-acre main medical center campus, the 36-acre Gottlieb Memorial Hospital campus and 25 primary and specialty care facilities in Cook, Will and DuPage counties. The medical center campus is conveniently located in Maywood, 13 miles west of the Chicago Loop and 8 miles east of Oak Brook, Ill. The heart of the medical center campus, Loyola University Hospital, is a 570-licensed bed facility. It houses a Level 1 Trauma Center, a Burn Center and the Ronald McDonald® Children?s Hospital of Loyola University Medical Center. Also on campus are the Cardinal Bernardin Cancer Center, Loyola Outpatient Center, Center for Heart & Vascular Medicine and Loyola Oral Health Center as well as the LUC Stritch School of Medicine, the LUC Marcella Niehoff School of Nursing and the Loyola Center for Fitness. Loyola's Gottlieb campus in Melrose Park includes the 250-bed community hospital, the Gottlieb Center for Fitness and the Marjorie G. Weinberg Cancer Care Center.
http://loyolamedicine.org/News/News_Releases/news_release_detail.cfm?var_news_release_id=973440913
Thursday, March 26, 2009
Urine Test May ID Unhealthy Diets
Low potassium level indicates poor nutrition, study finds
Posted March 26, 2009
By Kathleen Doheny
HealthDay Reporter
THURSDAY, March 26 (HealthDay News) -- Someday, a doctor's office assessment of the overall quality of your diet may come from a simple $8 urine test, researchers report.
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Levels of urinary potassium correlate closely with nutrition in general, said study author Dr. Alexander Logan, a professor of medicine at the University of Toronto.
"We can identify people who are eating a poor quality diet by a simple urine test and can recommend an intervention," said Logan, who is also senior scientist at the university's Samuel Lunenfeld Research Institute.
Simply questioning people about their diet isn't as foolproof, he added. "One can get a general idea of [intake of] fruits, vegetables and dairy by asking," he said. But self-reports are notoriously inaccurate. So, Logan's team evaluated 24-hour urine samples from 220 people, aged 18 to 50, all diagnosed with kidney stones.
The participants answered food questionnaires about their food intake and had their weight, height and blood pressure measured.
Logan's team then looked to see if urinary potassium and sodium levels could correlate to diet quality.
They found that the higher the potassium level in urine, the higher the intake of recommended healthy foods such as fruits, vegetables, whole grains and low-fat dairy products.
The lower the potassium, the more likely the food reports were to include more red meat, fast food and sugary, high-calorie drinks.
Those with the highest levels of urinary potassium also tended to have a lower body mass index (BMI), lower diastolic blood pressure and a lower heart rate than did those with lower levels. For instance, people with the highest potassium levels averaged a BMI of 26.5 (under 25 is desirable), while those with the lowest potassium levels had an average BMI of 28.7 (a BMI of 30 is the accepted threshold for obesity).
Sodium levels were not associated with any of those variables, the team found.
The study is published in the April 2009 issue of The Journal of Nutrition.
The Logan research is "an excellent study," said Judith Stern, a distinguished professor of nutrition at the University of California at Davis, who was not involved in the study but reviewed it. Consumers might ask their physician for the test to see if their diet is as healthy as they might think, she said.
"This study supports the [medical] literature that the amount of potassium in urine may objectively measure diet quality," added Jeannie Gazzaniga-Moloo, a dietitian in Roseville, Calif., and a spokeswoman for the American Dietetic Association. "However, the study looked at 24-hour urine collections, which are cumbersome, time-consuming and impractical for some patients," she said.
Moloo called for more research to further validate the findings.
Logan said his team can probably simplify the test to make it a one-time measurement. In the meantime, he advises consumers to pay attention to their fruit and vegetable intake and to follow other healthy dietary guidelines, such as eating three servings of dairy products a day, choosing either low- or no-fat varieties if weight control is a concern.
Logan said his team also plans to study the value of the test in people besides those with kidney disease, including those with irritable bowel syndrome, many of whom eat a poor diet.
More information
To learn more about the dietary guidelines, visit the U.S. Department of Health and Human Services.
Posted March 26, 2009
By Kathleen Doheny
HealthDay Reporter
THURSDAY, March 26 (HealthDay News) -- Someday, a doctor's office assessment of the overall quality of your diet may come from a simple $8 urine test, researchers report.
People Who Read This Also Read
U.S. Asked to Do More for Kids' Mental Health
Good Parents, Bad Results
Few Hospitals Embracing Electronic Health Record Systems
Using Too Much Salt Is Common in U.S., CDC Says
Yale Lab Discovers New Gene-Based Syndrome
Levels of urinary potassium correlate closely with nutrition in general, said study author Dr. Alexander Logan, a professor of medicine at the University of Toronto.
"We can identify people who are eating a poor quality diet by a simple urine test and can recommend an intervention," said Logan, who is also senior scientist at the university's Samuel Lunenfeld Research Institute.
Simply questioning people about their diet isn't as foolproof, he added. "One can get a general idea of [intake of] fruits, vegetables and dairy by asking," he said. But self-reports are notoriously inaccurate. So, Logan's team evaluated 24-hour urine samples from 220 people, aged 18 to 50, all diagnosed with kidney stones.
The participants answered food questionnaires about their food intake and had their weight, height and blood pressure measured.
Logan's team then looked to see if urinary potassium and sodium levels could correlate to diet quality.
They found that the higher the potassium level in urine, the higher the intake of recommended healthy foods such as fruits, vegetables, whole grains and low-fat dairy products.
The lower the potassium, the more likely the food reports were to include more red meat, fast food and sugary, high-calorie drinks.
Those with the highest levels of urinary potassium also tended to have a lower body mass index (BMI), lower diastolic blood pressure and a lower heart rate than did those with lower levels. For instance, people with the highest potassium levels averaged a BMI of 26.5 (under 25 is desirable), while those with the lowest potassium levels had an average BMI of 28.7 (a BMI of 30 is the accepted threshold for obesity).
Sodium levels were not associated with any of those variables, the team found.
The study is published in the April 2009 issue of The Journal of Nutrition.
The Logan research is "an excellent study," said Judith Stern, a distinguished professor of nutrition at the University of California at Davis, who was not involved in the study but reviewed it. Consumers might ask their physician for the test to see if their diet is as healthy as they might think, she said.
"This study supports the [medical] literature that the amount of potassium in urine may objectively measure diet quality," added Jeannie Gazzaniga-Moloo, a dietitian in Roseville, Calif., and a spokeswoman for the American Dietetic Association. "However, the study looked at 24-hour urine collections, which are cumbersome, time-consuming and impractical for some patients," she said.
Moloo called for more research to further validate the findings.
Logan said his team can probably simplify the test to make it a one-time measurement. In the meantime, he advises consumers to pay attention to their fruit and vegetable intake and to follow other healthy dietary guidelines, such as eating three servings of dairy products a day, choosing either low- or no-fat varieties if weight control is a concern.
Logan said his team also plans to study the value of the test in people besides those with kidney disease, including those with irritable bowel syndrome, many of whom eat a poor diet.
More information
To learn more about the dietary guidelines, visit the U.S. Department of Health and Human Services.
Tuesday, March 3, 2009
Harvard Medical School in Ethics Quandary
Harvard Medical School students like Kirsten Austad, left; Lekshmi Santhosh, Kim Sue and David Tian, members of the American Medical Student Association, object to the influence of drug companies in the school’s educational curriculum.
By DUFF WILSON
BOSTON — In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.
Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.
“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”
Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.
They say they are concerned that the same money that helped build the school’s world-class status may in fact be hurting its reputation and affecting its teaching.
The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.
Harvard Medical School’s peers received much higher grades, ranging from the A for the University of Pennsylvania, to B’s received by Stanford, Columbia and New York University, to the C for Yale.
Harvard has fallen behind, some faculty and administrators say, because its teaching hospitals are not owned by the university, complicating reform; because the dean is fairly new and his predecessor was such an industry booster that he served on a pharmaceutical company board; and because a crackdown, simply put, could cost it money or faculty.
Further, the potential embarrassments — a Senate investigation of several medical professors, the F grade, a new state law effective July 1 requiring Massachusetts doctors to disclose corporate gifts over $50 — are only now adding to pressure for change.
The dean, Dr. Jeffrey S. Flier, who says he wants Harvard to catch up with the best practices at other leading medical schools, recently announced a 19-member committee to re-examine his school’s conflict-of-interest policies. The group, which includes three students, is to meet in private on Thursday.
Advising the group will be Dr. David Korn, a former dean of the Stanford Medical School who started work at Harvard about four months ago as vice provost for research. Last year he helped the Association of American Medical Colleges draft a model conflict-of-interest policy for medical schools.
The Harvard students have already secured a requirement that all professors and lecturers disclose their industry ties in class — a blanket policy that has been adopted by no other leading medical school. (One Harvard professor’s disclosure in class listed 47 company affiliations.)
“Harvard needs to live up to its name,” said Kirsten Austad, 24, a first-year Harvard Medical student who is one of the movement’s leaders. “We are really being indoctrinated into a field of medicine that is becoming more and more commercialized.”
David Tian, 24, a first-year Harvard Medical student, said: “Before coming here, I had no idea how much influence companies had on medical education. And it’s something that’s purposely meant to be under the table, providing information under the guise of education when that information is also presented for marketing purposes.”
The students say they worry that pharmaceutical industry scandals in recent years — including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims — have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members.
Dr. Flier says that the Harvard Medical faculty may lead the nation in receiving money from industry, as well as government and charities, and he does not want to tighten the spigot. “One entirely appropriate source, if done properly, is industrial funds,” Dr. Flier said in an interview.
And school officials see corporate support for their faculty as all the more crucial, as the university endowment has lost 22 percent of its value since last July and the recession has caused philanthropic contributors to retrench. The school said it was unable to provide annual measures of the money flow to its faculty, beyond the $8.6 million that pharmaceutical companies contributed last year for basic science research and the $3 million for continuing education classes on campus. Most of the money goes to professors at the Harvard-affiliated teaching hospitals, and the dean’s office does not keep track of the total.
But no one disputes that many individual Harvard Medical faculty members receive tens or even hundreds of thousands of dollars a year through industry consulting and speaking fees. Under the school’s disclosure rules, about 1,600 of 8,900 professors and lecturers have reported to the dean that they or a family member had a financial interest in a business related to their teaching, research or clinical care. The reports show 149 with financial ties to Pfizer and 130 with Merck.
The rules, though, do not require them to report specific amounts received for speaking or consulting, other than broad indications like “more than $30,000.” Some faculty who conduct research have limits of $30,000 in stock and $20,000 a year in fees. But there are no limits on companies’ making outright gifts to faculty — free meals, tickets, trips or the like.
Other blandishments include industry-endowed chairs like the three Harvard created with $8 million from sleep research companies; faculty prizes like the $50,000 award named after Bristol-Myers Squibb, and sponsorships like Pfizer’s $1 million annual subsidy for 20 new M.D.’s in a two-year program to learn clinical investigation and pursue Harvard Master of Medical Science degrees, including classes taught by Pfizer scientists.
Dr. Flier, who became dean 17 months ago, previously received a $500,000 research grant from Bristol-Myers Squibb. He also consulted for three Cambridge biotechnology companies, but says that those relationships have ended and that he has accepted no new industry affiliations.
That is in contrast to his predecessor as dean, Dr. Joseph B. Martin. Harvard’s rules allowed Dr. Martin to sit on the board of the medical products company Baxter International for 5 of the 10 years he led the medical school, supplementing his university salary with up to $197,000 a year from Baxter, according to company filings.
Dr. Martin is still on the medical faculty and is founder and co-chairman of the Harvard NeuroDiscovery Center, which researches degenerative diseases, and actively solicits industry money to do so. Dr. Martin declined any comment.
A smaller rival faction among Harvard’s 750 medical students has circulated a petition signed by about 100 people that calls for “continued interaction between medicine and industry at Harvard Medical School.”
A leader of the group, Vijay Yanamadala, 22, said, “To say that because these industry sources are inherently biased, physicians should never listen to them, is wrong.”
Encouraging them is Dr. Thomas P. Stossel, a Harvard Medical professor who has served on advisory boards for Merck, Biogen Idec and Dyax, and has written widely on academic-industry ties. “I think if you look at it with intellectual honesty, you see industry interaction has produced far more good than harm,” Dr. Stossel said. “Harvard absolutely could get more from industry but I think they’re very skittish. There’s a huge opportunity we ought to mine.”
Brian Fuchs, 26, a second-year student from Queens, credited drug companies with great medical discoveries. “It’s not a problem,” he said, pointing out a classroom window to a 12-story building nearby. “In fact, Merck is right there.”
Merck built a corporate research center in 2004 across the street from Harvard’s own big new medical research and class building. And Merck underwrites plenty of work on the Harvard campus, including the immunology lab run by Dr. Laurie H. Glimcher — a professor who also sits on the board of the drug maker Bristol-Myers Squibb, which paid her nearly $270,000 in 2007.
Dr. Glimcher says industry money is not only appropriate but necessary. “Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,” she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year. But Dr. Marcia Angell, a faculty member and former editor in chief of The New England Journal of Medicine, is among the professors who argue that industry profit motives do not correspond to the scientific aims of academic medicine and that much of the financing needs to be not only disclosed, but banned. Too many medical schools, she says, have struck a “Faustian bargain” with pharmaceutical companies.
“If a school like Harvard can’t behave itself,” Dr. Angell said, “who can?”
Monday, March 2, 2009
Good or Useless, Medical Scans Cost the Same
By GINA KOLATA
When Gail Kislevitz had an M.R.I. scan of her knee, it came back blurry, “uninterpretable,” her orthopedist told her.
A poor-quality scan of a ligament, left, and one of high quality. Many scans are done by machines that are a decade old.
Her insurer refused to pay for another scan, but the doctor said he was sure she had torn cartilage that stabilizes the knee and suggested an operation to fix it. After the surgery, Ms. Kislevitz, 57, of Ridgewood, N.J., received a surprise: the cartilage had not been torn after all.
She had a long rehabilitation. And her insurer paid for the operation. But her knee is no better.
More than 95 million high-tech scans are done each year, and medical imaging, including CT, M.R.I. and PET scans, has ballooned into a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. But recent studies show that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients.
“The system is just totally, totally broken,” said Dr. Vijay Rao, the chairwoman of the radiology department at Thomas Jefferson University Hospital, in Philadelphia.
Radiologists say a decent M.R.I. scan should have clearly shown whether the cartilage in Ms. Kislevitz, a meniscus, was torn. But bad scans, medical experts say, are part of a growing problem with medical imaging.
Many factors contribute. Insurers pay the same for a scan done on a 10-year-old machine as one on the latest model, though the differences in the images can be significant.
Insurers do not distinguish between scans that are done poorly or done well or read by less- or more-qualified doctors. Aside from mammography, whose standards were established by a law that went into effect more than a decade ago, the field is largely unregulated. And increasingly, doctors refer patients to scanning centers they own and profit from.
Ten years ago, the age of a scanner might not have mattered so much. Now, said Dr. Gary Glazer, the chairman of radiology at Stanford, technology has advanced so much that the older scanner “is not the same machine.”
“I can tell you from my experience that between those extremes the gap is huge,” Dr. Glazer said.
Yet, he added, many scanning machines used today are a decade old.
Imaging centers can, if they choose, become accredited by the American College of Radiology. That requires, among other things, scanning a phantom, a device that simulates a body part. Technologists must also be certified, and there are standards for supervising physicians. And the scanners must be regularly assessed to ensure they are properly functioning.
But many centers are not accredited, although the percentage is not known because there is no national registry of imaging centers.
Accrediting will be partly addressed by a little noticed aspect of a wide-ranging Medicare law passed last year. After it goes into effect in 2012, Medicare will pay only for scans done at accredited centers. But imaging experts say the law fixes only part of the problem. High-tech scanning is complicated, and there is no consensus on objective measures to ensure quality. Even with the new law, there is still little assurance that scans will be appropriately ordered and interpreted or that a scanner will be up to date.
Radiologists are struck by the wide variation in the quality of scans, and they say there is little patients can do other than to ask why the scan is necessary and, if it is, to ask about accreditation, the credentials of the person reading the scan and the age of the scanner.
“The studies I see coming from the outside vary from marginal quality to very good quality,” said Dr. Chris Beaulieu, a Stanford radiology professor. “Some of it is related to equipment, and some is related to people with very good equipment who don’t know how to use it right. And on the interpretation side, there is also a very wide range of quality or accuracy, in my opinion.”
Interpretation can be crucial, Dr. Beaulieu added. “A good radiologist can sometimes accurately read scans off of a lower-quality scanner,” he said. “I see that all the time. A good radiologist and a lower-quality scan could be better than a bad radiologist and a good scan.”
But logical as it might seem to pay more for a better scan, there are problems. Health insurers have no way of knowing whether scans are good, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group. Doctors, not insurers, receive the images and reports, and all insurers can do is notice if there are frequent requests to redo scans from a particular center.
“We see a lot of poor-quality scans,” said Dr. Freddie Fu, the chairman of the orthopedic surgery department at the University of Pittsburgh Medical Center. “I joke with the patients: The insurance pays the same amount of money for the scan. You get a hamburger somewhere else and a prime rib here for the same price.”
Another concern is the growing number of doctors who refer patients for imaging done by scanners they own and profit from. Studies have found that up to 3.2 times as many scans are ordered in such cases
In a recent report, the Government Accountability Office said nearly two-thirds of the money Medicare paid for imaging was for scans in doctors’ offices. And, the report added, doctors were receiving an ever larger part of their income from providing scanning services. Not only were patients more likely to have scans if a doctor did this, but the quality of some of the scans was questioned.
“No comprehensive national standards exist for services delivered in physician offices other than a requirement that imaging services are to be provided under at least general physician supervision,” the G.A.O. wrote.
Private health insurers were concerned, too. “These are alarming patterns that have also been observed in the private sector,” America’s Health Insurance Plans wrote in a response to the G.A.O.
It is clear why self-referral can be tempting, said Dr. Bruce Hillman, a radiology professor at the University of Virginia.
“It’s all profits,” Dr. Hillman said, adding that a group of doctors can make an extra $500,000 to $1 million a year simply by acquiring a scanner.
For now, radiologists said, patients and insurers are often in a bind.
“If you are going to buy a car,” said Dr. Beaulieu, the Stanford professor, “and you have a certain amount of money to spend, you know what you are getting. You know what you will get if you buy a Yugo or if you buy a BMW.”
But with imaging, Dr. Beaulieu said, “you don’t know: you might get a Yugo and you might get a BMW.”
When Gail Kislevitz had an M.R.I. scan of her knee, it came back blurry, “uninterpretable,” her orthopedist told her.
A poor-quality scan of a ligament, left, and one of high quality. Many scans are done by machines that are a decade old.
Her insurer refused to pay for another scan, but the doctor said he was sure she had torn cartilage that stabilizes the knee and suggested an operation to fix it. After the surgery, Ms. Kislevitz, 57, of Ridgewood, N.J., received a surprise: the cartilage had not been torn after all.
She had a long rehabilitation. And her insurer paid for the operation. But her knee is no better.
More than 95 million high-tech scans are done each year, and medical imaging, including CT, M.R.I. and PET scans, has ballooned into a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. But recent studies show that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients.
“The system is just totally, totally broken,” said Dr. Vijay Rao, the chairwoman of the radiology department at Thomas Jefferson University Hospital, in Philadelphia.
Radiologists say a decent M.R.I. scan should have clearly shown whether the cartilage in Ms. Kislevitz, a meniscus, was torn. But bad scans, medical experts say, are part of a growing problem with medical imaging.
Many factors contribute. Insurers pay the same for a scan done on a 10-year-old machine as one on the latest model, though the differences in the images can be significant.
Insurers do not distinguish between scans that are done poorly or done well or read by less- or more-qualified doctors. Aside from mammography, whose standards were established by a law that went into effect more than a decade ago, the field is largely unregulated. And increasingly, doctors refer patients to scanning centers they own and profit from.
Ten years ago, the age of a scanner might not have mattered so much. Now, said Dr. Gary Glazer, the chairman of radiology at Stanford, technology has advanced so much that the older scanner “is not the same machine.”
“I can tell you from my experience that between those extremes the gap is huge,” Dr. Glazer said.
Yet, he added, many scanning machines used today are a decade old.
Imaging centers can, if they choose, become accredited by the American College of Radiology. That requires, among other things, scanning a phantom, a device that simulates a body part. Technologists must also be certified, and there are standards for supervising physicians. And the scanners must be regularly assessed to ensure they are properly functioning.
But many centers are not accredited, although the percentage is not known because there is no national registry of imaging centers.
Accrediting will be partly addressed by a little noticed aspect of a wide-ranging Medicare law passed last year. After it goes into effect in 2012, Medicare will pay only for scans done at accredited centers. But imaging experts say the law fixes only part of the problem. High-tech scanning is complicated, and there is no consensus on objective measures to ensure quality. Even with the new law, there is still little assurance that scans will be appropriately ordered and interpreted or that a scanner will be up to date.
Radiologists are struck by the wide variation in the quality of scans, and they say there is little patients can do other than to ask why the scan is necessary and, if it is, to ask about accreditation, the credentials of the person reading the scan and the age of the scanner.
“The studies I see coming from the outside vary from marginal quality to very good quality,” said Dr. Chris Beaulieu, a Stanford radiology professor. “Some of it is related to equipment, and some is related to people with very good equipment who don’t know how to use it right. And on the interpretation side, there is also a very wide range of quality or accuracy, in my opinion.”
Interpretation can be crucial, Dr. Beaulieu added. “A good radiologist can sometimes accurately read scans off of a lower-quality scanner,” he said. “I see that all the time. A good radiologist and a lower-quality scan could be better than a bad radiologist and a good scan.”
But logical as it might seem to pay more for a better scan, there are problems. Health insurers have no way of knowing whether scans are good, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group. Doctors, not insurers, receive the images and reports, and all insurers can do is notice if there are frequent requests to redo scans from a particular center.
“We see a lot of poor-quality scans,” said Dr. Freddie Fu, the chairman of the orthopedic surgery department at the University of Pittsburgh Medical Center. “I joke with the patients: The insurance pays the same amount of money for the scan. You get a hamburger somewhere else and a prime rib here for the same price.”
Another concern is the growing number of doctors who refer patients for imaging done by scanners they own and profit from. Studies have found that up to 3.2 times as many scans are ordered in such cases
In a recent report, the Government Accountability Office said nearly two-thirds of the money Medicare paid for imaging was for scans in doctors’ offices. And, the report added, doctors were receiving an ever larger part of their income from providing scanning services. Not only were patients more likely to have scans if a doctor did this, but the quality of some of the scans was questioned.
“No comprehensive national standards exist for services delivered in physician offices other than a requirement that imaging services are to be provided under at least general physician supervision,” the G.A.O. wrote.
Private health insurers were concerned, too. “These are alarming patterns that have also been observed in the private sector,” America’s Health Insurance Plans wrote in a response to the G.A.O.
It is clear why self-referral can be tempting, said Dr. Bruce Hillman, a radiology professor at the University of Virginia.
“It’s all profits,” Dr. Hillman said, adding that a group of doctors can make an extra $500,000 to $1 million a year simply by acquiring a scanner.
For now, radiologists said, patients and insurers are often in a bind.
“If you are going to buy a car,” said Dr. Beaulieu, the Stanford professor, “and you have a certain amount of money to spend, you know what you are getting. You know what you will get if you buy a Yugo or if you buy a BMW.”
But with imaging, Dr. Beaulieu said, “you don’t know: you might get a Yugo and you might get a BMW.”
Friday, February 27, 2009
What’s Eating Our Kids? Fears About ‘Bad’ Foods
February 26, 2009
By ABBY ELLIN
SODIUM — that’s what worries Greye Dunn. He thinks about calories, too, and whether he’s getting enough vitamins. But it’s the sodium that really scares him.
“Sodium makes your heart beat faster, so it can create something really serious,” said Greye, who is 8 years old and lives in Mays Landing, N.J.
Greye’s mother, Beth Dunn, the president of a multimedia company, is proud of her son’s nutritional awareness and encourages it by serving organic food and helping Greye read labels on cereal boxes and cans.
“He wants to be healthy,” she says.
Ms. Dunn is among the legions of parents who are vigilant about their children’s consumption of sugar, processed foods and trans fats. Many try to stick to an organic diet. In general, their concern does not stem from a fear of obesity — although that may figure into the equation — but from a desire to protect their families from conditions like hyperactivity, diabetes and heart disease, which they believe can be avoided, or at least managed, by careful eating.
While scarcely any expert would criticize parents for paying attention to children’s diets, many doctors, dietitians and eating disorder specialists worry that some parents are becoming overzealous, even obsessive, in efforts to engender good eating habits in children. With the best of intentions, these parents may be creating an unhealthy aura around food.
“We’re seeing a lot of anxiety in these kids,” said Cynthia Bulik, the director of the eating disorders program at the University of North Carolina at Chapel Hill. “They go to birthday parties, and if it’s not a granola cake they feel like they can’t eat it. The culture has led both them and their parents to take the public health messages to an extreme.”
Tiffany Rush-Wilson, an eating disorder counselor in Pepper Pike, Ohio, has seen the same thing. “I have lots of children or adolescent clients or young adults who complain about how their parents micromanage their eating based on their own health standards and beliefs,” she said. “The kids’ eating became very restrictive, and that’s how they came to me.”
Certainly, not all parents who enforce rules about healthy food — or any dietary plan — are setting their children up for an eating disorder. Clinical disorders like anorexia nervosa and bulimia, which have been diagnosed in increasing numbers of adolescents and young people in the last two decades, are thought by researchers to have a variety of causes — including genetics, the influence of mass media and social pressure.
To date, there have been no formal studies on whether parents’ obsession with health food can lead to eating disorders. Some experts say an extreme obsession with health food is merely a symptom, not a cause, of an eating disorder.
But even without firm numbers, anecdotal reports from specialists suggest that a preoccupation with avoiding “bad” foods is an issue for many young people who seek help.
Dr. James Greenblatt, the chief medical officer at Walden Behavioral Care, a hospital specializing in child and adult eating disorders in Waltham, Mass., estimates that he has recently seen about a 15 percent rise in the number of his young patients who eat only organic foods to avoid pesticides.
“A lot of the patients we have seen over the last six years limited refined sugar and high fat foods because of concerns about gaining weight,” he said. “But now, these worries are often expressed in terms of health concerns.”
Lisa Dorfman, a registered dietitian and the director of sports nutrition and performance at the University of Miami, says that she often sees children who are terrified of foods that are deemed “bad” by parents. “It’s almost a fear of dying, a fear of illness, like a delusional view of foods in general,” she said. “I see kids whose parents have hypnotized them. I have 5-year-olds that speak like 40-year-olds. They can’t eat an Oreo cookie without being concerned about trans fats.”
Dr. Steven Bratman of Denver has come up with a term to describe people obsessed with health food: orthorexia. Orthorexic patients, he says, are fixated on “righteous eating” (the word stems from the Greek word ortho, meaning straight and correct).
“I would tell them, ‘You’re addicted to health food.’ It was my way of having them not take themselves so seriously,” said Dr. Bratman, who published a book on the subject, “Health Food Junkies,” in 2001.
The condition, he says, may begin in homes where there is a preoccupation with “health foods.”
Many eating disorder experts dispute the concept. They say that orthorexia, which is not considered a clinical diagnosis, is merely a form of anorexia nervosa or obsessive compulsive disorder.
Angelique A. Sallas, a clinical psychologist in Chicago, says the idea of a “health food disorder” is practically meaningless. “I don’t think the symptoms are significantly different enough from bulimia or anorexia that it deserves a special diagnostic category,” Dr. Sallas said. “It’s an obsessive-compulsive problem. The object of the obsession is less relevant than the fact that they are engaging in obsessive behavior.”
Dr. David Hahn, the assistant medical director at the Renfrew Center, an eating disorders clinic in Philadelphia, also thinks that orthorexics are anorexics in disguise. “I see many patients that are overly concerned with the quality of their food, and that’s the way they express their eating disorder,” he said.
But whatever the behavior is called, those who have lived through a disorder fueled by an obsession with healthful eating say that the experience can be agonizing. Kristie Rutzel, a 26-year-old marketing coordinator in Richmond, Va., began eliminating carbohydrates, meats, refined sugars and processed foods from her diet at 18. She became so fixated on eating only “pure” foods, she said, that she slashed her daily calorie intake to 500. Eventually, her weight fell to 68 pounds and she was repeatedly hospitalized for anorexia.
Today Ms. Rutzel, who said she is normal weight, often talks to young girls in schools and churches about the perils of becoming health-food obsessed.
Laura Collins, a writer who lives in Virginia, was once a parent who was always “moralizing about good and bad foods,” she said. “We didn’t serve candy, my kids didn’t have soda.” Ms. Collins’s daughter, Olympia, became rigid in her eating, fearing food that she worried would make her unhealthy. By age 14, Olympia developed anorexia, her mother said. To help her recover, the family had to rethink its entire approach to food.
Some experts are quick to point out that it is not only parents who may contribute to children’s food anxieties. They cite nutritional programs in schools that may go overboard. “I see younger kids who have an eating disorder precipitated by a nutrition lesson in school,” said Dr. Leslie Sanders, medical director of the eating disorders program at Atlantic Health Overlook Hospital in Summit, N.J.
Over the last five years, Dr. Sanders said, she has seen a rise in the number of children who are fixated on the way they eat: “Some educators categorize food into ‘good’ and ‘bad.’ The kids come home and say ‘Don’t eat French fries’ instead of talking about moderation.”
The problem, according to some nutritional experts, is that many teachers don’t understand nutrition well. “We’re driving our kids absolutely crazy,” said Katie Wilson, president of the School Nutrition Association. “All the stuff about preservatives and pesticides. All an 8-year-old kid should know is that he or she should eat a variety of colors, and don’t supersize anything but your water jug.”
Nina Planck, author of “Real Food: What to Eat and Why,” said that it’s a “total cop out” to lay blame on schools and parents for children’s eating disorders. “The eating disorder comes out of a disordered psyche,” she said. “You can’t blame the information for causing the eating disorders.”
But Jessica Setnick, a dietitian in Dallas and author of “The Eating Disorders Clinical Pocket Guide,” tells a story that suggests parents’ attitudes can affect children. She recalled a mother who brought in her preteen, apparently bulimic daughter. As Ms. Setnick discovered, the girl was not trying to lose weight. “Her mother only served brown rice, but she didn’t like it,” Ms. Setnick said. “She did like white rice. And while I’m not going to tell anyone what they can bring into their own home, we discussed that when the family went out, it would be O.K. to get white rice.”
When the girl told her mother what Ms. Setnick said, the mother was furious, according to Ms. Setnick. “She said, ‘Don’t you know white rice is just like sugar?’ ”
“My heart broke for that girl,” Ms. Setnick said. “She was telling her mother what she needed, and the mother wasn’t listening.”
Ms. Collins, the author of “Eating with Your Anorexic,” a book about her daughter’s struggle with anorexia, and director of the nonprofit organization Feast (Families Empowered and Supporting Treatment of Eating Disorders), offers some perspective.
“It’s a tragedy that we’ve developed this moralistic, restrictive and unhappy relationship” with eating, she said. “I think it is making kids nutty, it’s sucking the life out of our relationship with food.”
By ABBY ELLIN
SODIUM — that’s what worries Greye Dunn. He thinks about calories, too, and whether he’s getting enough vitamins. But it’s the sodium that really scares him.
“Sodium makes your heart beat faster, so it can create something really serious,” said Greye, who is 8 years old and lives in Mays Landing, N.J.
Greye’s mother, Beth Dunn, the president of a multimedia company, is proud of her son’s nutritional awareness and encourages it by serving organic food and helping Greye read labels on cereal boxes and cans.
“He wants to be healthy,” she says.
Ms. Dunn is among the legions of parents who are vigilant about their children’s consumption of sugar, processed foods and trans fats. Many try to stick to an organic diet. In general, their concern does not stem from a fear of obesity — although that may figure into the equation — but from a desire to protect their families from conditions like hyperactivity, diabetes and heart disease, which they believe can be avoided, or at least managed, by careful eating.
While scarcely any expert would criticize parents for paying attention to children’s diets, many doctors, dietitians and eating disorder specialists worry that some parents are becoming overzealous, even obsessive, in efforts to engender good eating habits in children. With the best of intentions, these parents may be creating an unhealthy aura around food.
“We’re seeing a lot of anxiety in these kids,” said Cynthia Bulik, the director of the eating disorders program at the University of North Carolina at Chapel Hill. “They go to birthday parties, and if it’s not a granola cake they feel like they can’t eat it. The culture has led both them and their parents to take the public health messages to an extreme.”
Tiffany Rush-Wilson, an eating disorder counselor in Pepper Pike, Ohio, has seen the same thing. “I have lots of children or adolescent clients or young adults who complain about how their parents micromanage their eating based on their own health standards and beliefs,” she said. “The kids’ eating became very restrictive, and that’s how they came to me.”
Certainly, not all parents who enforce rules about healthy food — or any dietary plan — are setting their children up for an eating disorder. Clinical disorders like anorexia nervosa and bulimia, which have been diagnosed in increasing numbers of adolescents and young people in the last two decades, are thought by researchers to have a variety of causes — including genetics, the influence of mass media and social pressure.
To date, there have been no formal studies on whether parents’ obsession with health food can lead to eating disorders. Some experts say an extreme obsession with health food is merely a symptom, not a cause, of an eating disorder.
But even without firm numbers, anecdotal reports from specialists suggest that a preoccupation with avoiding “bad” foods is an issue for many young people who seek help.
Dr. James Greenblatt, the chief medical officer at Walden Behavioral Care, a hospital specializing in child and adult eating disorders in Waltham, Mass., estimates that he has recently seen about a 15 percent rise in the number of his young patients who eat only organic foods to avoid pesticides.
“A lot of the patients we have seen over the last six years limited refined sugar and high fat foods because of concerns about gaining weight,” he said. “But now, these worries are often expressed in terms of health concerns.”
Lisa Dorfman, a registered dietitian and the director of sports nutrition and performance at the University of Miami, says that she often sees children who are terrified of foods that are deemed “bad” by parents. “It’s almost a fear of dying, a fear of illness, like a delusional view of foods in general,” she said. “I see kids whose parents have hypnotized them. I have 5-year-olds that speak like 40-year-olds. They can’t eat an Oreo cookie without being concerned about trans fats.”
Dr. Steven Bratman of Denver has come up with a term to describe people obsessed with health food: orthorexia. Orthorexic patients, he says, are fixated on “righteous eating” (the word stems from the Greek word ortho, meaning straight and correct).
“I would tell them, ‘You’re addicted to health food.’ It was my way of having them not take themselves so seriously,” said Dr. Bratman, who published a book on the subject, “Health Food Junkies,” in 2001.
The condition, he says, may begin in homes where there is a preoccupation with “health foods.”
Many eating disorder experts dispute the concept. They say that orthorexia, which is not considered a clinical diagnosis, is merely a form of anorexia nervosa or obsessive compulsive disorder.
Angelique A. Sallas, a clinical psychologist in Chicago, says the idea of a “health food disorder” is practically meaningless. “I don’t think the symptoms are significantly different enough from bulimia or anorexia that it deserves a special diagnostic category,” Dr. Sallas said. “It’s an obsessive-compulsive problem. The object of the obsession is less relevant than the fact that they are engaging in obsessive behavior.”
Dr. David Hahn, the assistant medical director at the Renfrew Center, an eating disorders clinic in Philadelphia, also thinks that orthorexics are anorexics in disguise. “I see many patients that are overly concerned with the quality of their food, and that’s the way they express their eating disorder,” he said.
But whatever the behavior is called, those who have lived through a disorder fueled by an obsession with healthful eating say that the experience can be agonizing. Kristie Rutzel, a 26-year-old marketing coordinator in Richmond, Va., began eliminating carbohydrates, meats, refined sugars and processed foods from her diet at 18. She became so fixated on eating only “pure” foods, she said, that she slashed her daily calorie intake to 500. Eventually, her weight fell to 68 pounds and she was repeatedly hospitalized for anorexia.
Today Ms. Rutzel, who said she is normal weight, often talks to young girls in schools and churches about the perils of becoming health-food obsessed.
Laura Collins, a writer who lives in Virginia, was once a parent who was always “moralizing about good and bad foods,” she said. “We didn’t serve candy, my kids didn’t have soda.” Ms. Collins’s daughter, Olympia, became rigid in her eating, fearing food that she worried would make her unhealthy. By age 14, Olympia developed anorexia, her mother said. To help her recover, the family had to rethink its entire approach to food.
Some experts are quick to point out that it is not only parents who may contribute to children’s food anxieties. They cite nutritional programs in schools that may go overboard. “I see younger kids who have an eating disorder precipitated by a nutrition lesson in school,” said Dr. Leslie Sanders, medical director of the eating disorders program at Atlantic Health Overlook Hospital in Summit, N.J.
Over the last five years, Dr. Sanders said, she has seen a rise in the number of children who are fixated on the way they eat: “Some educators categorize food into ‘good’ and ‘bad.’ The kids come home and say ‘Don’t eat French fries’ instead of talking about moderation.”
The problem, according to some nutritional experts, is that many teachers don’t understand nutrition well. “We’re driving our kids absolutely crazy,” said Katie Wilson, president of the School Nutrition Association. “All the stuff about preservatives and pesticides. All an 8-year-old kid should know is that he or she should eat a variety of colors, and don’t supersize anything but your water jug.”
Nina Planck, author of “Real Food: What to Eat and Why,” said that it’s a “total cop out” to lay blame on schools and parents for children’s eating disorders. “The eating disorder comes out of a disordered psyche,” she said. “You can’t blame the information for causing the eating disorders.”
But Jessica Setnick, a dietitian in Dallas and author of “The Eating Disorders Clinical Pocket Guide,” tells a story that suggests parents’ attitudes can affect children. She recalled a mother who brought in her preteen, apparently bulimic daughter. As Ms. Setnick discovered, the girl was not trying to lose weight. “Her mother only served brown rice, but she didn’t like it,” Ms. Setnick said. “She did like white rice. And while I’m not going to tell anyone what they can bring into their own home, we discussed that when the family went out, it would be O.K. to get white rice.”
When the girl told her mother what Ms. Setnick said, the mother was furious, according to Ms. Setnick. “She said, ‘Don’t you know white rice is just like sugar?’ ”
“My heart broke for that girl,” Ms. Setnick said. “She was telling her mother what she needed, and the mother wasn’t listening.”
Ms. Collins, the author of “Eating with Your Anorexic,” a book about her daughter’s struggle with anorexia, and director of the nonprofit organization Feast (Families Empowered and Supporting Treatment of Eating Disorders), offers some perspective.
“It’s a tragedy that we’ve developed this moralistic, restrictive and unhappy relationship” with eating, she said. “I think it is making kids nutty, it’s sucking the life out of our relationship with food.”
Wednesday, January 28, 2009
Babies Know: A Little Dirt Is Good for You
January 27, 2009
Personal Health
By JANE E. BRODY
Ask mothers why babies are constantly picking things up from the floor or ground and putting them in their mouths, and chances are they’ll say that it’s instinctive — that that’s how babies explore the world. But why the mouth, when sight, hearing, touch and even scent are far better at identifying things?
When my young sons were exploring the streets of Brooklyn, I couldn’t help but wonder how good crushed rock or dried dog droppings could taste when delicious mashed potatoes were routinely rejected.
Since all instinctive behaviors have an evolutionary advantage or they would not have been retained for millions of years, chances are that this one too has helped us survive as a species. And, indeed, accumulating evidence strongly suggests that eating dirt is good for you.
In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.
These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.
Training the Immune System
“What a child is doing when he puts things in his mouth is allowing his immune response to explore his environment,” Mary Ruebush, a microbiology and immunology instructor, wrote in her new book, “Why Dirt Is Good” (Kaplan). “Not only does this allow for ‘practice’ of immune responses, which will be necessary for protection, but it also plays a critical role in teaching the immature immune response what is best ignored.”
One leading researcher, Dr. Joel V. Weinstock, the director of gastroenterology and hepatology at Tufts Medical Center in Boston, said in an interview that the immune system at birth “is like an unprogrammed computer. It needs instruction.”
He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they “also eliminated exposure to many organisms that are probably good for us.”
“Children raised in an ultraclean environment,” he added, “are not being exposed to organisms that help them develop appropriate immune regulatory circuits.”
Studies he has conducted with Dr. David Elliott, a gastroenterologist and immunologist at the University of Iowa, indicate that intestinal worms, which have been all but eliminated in developed countries, are “likely to be the biggest player” in regulating the immune system to respond appropriately, Dr. Elliott said in an interview. He added that bacterial and viral infections seem to influence the immune system in the same way, but not as forcefully.
Most worms are harmless, especially in well-nourished people, Dr. Weinstock said.
“There are very few diseases that people get from worms,” he said. “Humans have adapted to the presence of most of them.”
Worms for Health
In studies in mice, Dr. Weinstock and Dr. Elliott have used worms to both prevent and reverse autoimmune disease. Dr. Elliott said that in Argentina, researchers found that patients with multiple sclerosis who were infected with the human whipworm had milder cases and fewer flare-ups of their disease over a period of four and a half years. At the University of Wisconsin, Madison, Dr. John Fleming, a neurologist, is testing whether the pig whipworm can temper the effects of multiple sclerosis.
In Gambia, the eradication of worms in some villages led to children’s having increased skin reactions to allergens, Dr. Elliott said. And pig whipworms, which reside only briefly in the human intestinal tract, have had “good effects” in treating the inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, he said.
How may worms affect the immune system? Dr. Elliott explained that immune regulation is now known to be more complex than scientists thought when the hygiene hypothesis was first introduced by a British epidemiologist, David P. Strachan, in 1989. Dr. Strachan noted an association between large family size and reduced rates of asthma and allergies. Immunologists now recognize a four-point response system of helper T cells: Th 1, Th 2, Th 17 and regulatory T cells. Th 1 inhibits Th 2 and Th 17; Th 2 inhibits Th 1 and Th 17; and regulatory T cells inhibit all three, Dr. Elliott said.
“A lot of inflammatory diseases — multiple sclerosis, Crohn’s disease, ulcerative colitis and asthma — are due to the activity of Th 17,” he explained. “If you infect mice with worms, Th 17 drops dramatically, and the activity of regulatory T cells is augmented.”
In answer to the question, “Are we too clean?” Dr. Elliott said: “Dirtiness comes with a price. But cleanliness comes with a price, too. We’re not proposing a return to the germ-filled environment of the 1850s. But if we properly understand how organisms in the environment protect us, maybe we can give a vaccine or mimic their effects with some innocuous stimulus.”
Wash in Moderation
Dr. Ruebush, the “Why Dirt Is Good” author, does not suggest a return to filth, either. But she correctly points out that bacteria are everywhere: on us, in us and all around us. Most of these micro-organisms cause no problem, and many, like the ones that normally live in the digestive tract and produce life-sustaining nutrients, are essential to good health.
“The typical human probably harbors some 90 trillion microbes,” she wrote. “The very fact that you have so many microbes of so many different kinds is what keeps you healthy most of the time.”
Dr. Ruebush deplores the current fetish for the hundreds of antibacterial products that convey a false sense of security and may actually foster the development of antibiotic-resistant, disease-causing bacteria. Plain soap and water are all that are needed to become clean, she noted.
“I certainly recommend washing your hands after using the bathroom, before eating, after changing a diaper, before and after handling food,” and whenever they’re visibly soiled, she wrote. When no running water is available and cleaning hands is essential, she suggests an alcohol-based hand sanitizer.
Dr. Weinstock goes even further. “Children should be allowed to go barefoot in the dirt, play in the dirt, and not have to wash their hands when they come in to eat,” he said. He and Dr. Elliott pointed out that children who grow up on farms and are frequently exposed to worms and other organisms from farm animals are much less likely to develop allergies and autoimmune diseases.
Also helpful, he said, is to “let kids have two dogs and a cat,” which will expose them to intestinal worms that can promote a healthy immune system.
Personal Health
By JANE E. BRODY
Ask mothers why babies are constantly picking things up from the floor or ground and putting them in their mouths, and chances are they’ll say that it’s instinctive — that that’s how babies explore the world. But why the mouth, when sight, hearing, touch and even scent are far better at identifying things?
When my young sons were exploring the streets of Brooklyn, I couldn’t help but wonder how good crushed rock or dried dog droppings could taste when delicious mashed potatoes were routinely rejected.
Since all instinctive behaviors have an evolutionary advantage or they would not have been retained for millions of years, chances are that this one too has helped us survive as a species. And, indeed, accumulating evidence strongly suggests that eating dirt is good for you.
In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.
These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.
Training the Immune System
“What a child is doing when he puts things in his mouth is allowing his immune response to explore his environment,” Mary Ruebush, a microbiology and immunology instructor, wrote in her new book, “Why Dirt Is Good” (Kaplan). “Not only does this allow for ‘practice’ of immune responses, which will be necessary for protection, but it also plays a critical role in teaching the immature immune response what is best ignored.”
One leading researcher, Dr. Joel V. Weinstock, the director of gastroenterology and hepatology at Tufts Medical Center in Boston, said in an interview that the immune system at birth “is like an unprogrammed computer. It needs instruction.”
He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they “also eliminated exposure to many organisms that are probably good for us.”
“Children raised in an ultraclean environment,” he added, “are not being exposed to organisms that help them develop appropriate immune regulatory circuits.”
Studies he has conducted with Dr. David Elliott, a gastroenterologist and immunologist at the University of Iowa, indicate that intestinal worms, which have been all but eliminated in developed countries, are “likely to be the biggest player” in regulating the immune system to respond appropriately, Dr. Elliott said in an interview. He added that bacterial and viral infections seem to influence the immune system in the same way, but not as forcefully.
Most worms are harmless, especially in well-nourished people, Dr. Weinstock said.
“There are very few diseases that people get from worms,” he said. “Humans have adapted to the presence of most of them.”
Worms for Health
In studies in mice, Dr. Weinstock and Dr. Elliott have used worms to both prevent and reverse autoimmune disease. Dr. Elliott said that in Argentina, researchers found that patients with multiple sclerosis who were infected with the human whipworm had milder cases and fewer flare-ups of their disease over a period of four and a half years. At the University of Wisconsin, Madison, Dr. John Fleming, a neurologist, is testing whether the pig whipworm can temper the effects of multiple sclerosis.
In Gambia, the eradication of worms in some villages led to children’s having increased skin reactions to allergens, Dr. Elliott said. And pig whipworms, which reside only briefly in the human intestinal tract, have had “good effects” in treating the inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, he said.
How may worms affect the immune system? Dr. Elliott explained that immune regulation is now known to be more complex than scientists thought when the hygiene hypothesis was first introduced by a British epidemiologist, David P. Strachan, in 1989. Dr. Strachan noted an association between large family size and reduced rates of asthma and allergies. Immunologists now recognize a four-point response system of helper T cells: Th 1, Th 2, Th 17 and regulatory T cells. Th 1 inhibits Th 2 and Th 17; Th 2 inhibits Th 1 and Th 17; and regulatory T cells inhibit all three, Dr. Elliott said.
“A lot of inflammatory diseases — multiple sclerosis, Crohn’s disease, ulcerative colitis and asthma — are due to the activity of Th 17,” he explained. “If you infect mice with worms, Th 17 drops dramatically, and the activity of regulatory T cells is augmented.”
In answer to the question, “Are we too clean?” Dr. Elliott said: “Dirtiness comes with a price. But cleanliness comes with a price, too. We’re not proposing a return to the germ-filled environment of the 1850s. But if we properly understand how organisms in the environment protect us, maybe we can give a vaccine or mimic their effects with some innocuous stimulus.”
Wash in Moderation
Dr. Ruebush, the “Why Dirt Is Good” author, does not suggest a return to filth, either. But she correctly points out that bacteria are everywhere: on us, in us and all around us. Most of these micro-organisms cause no problem, and many, like the ones that normally live in the digestive tract and produce life-sustaining nutrients, are essential to good health.
“The typical human probably harbors some 90 trillion microbes,” she wrote. “The very fact that you have so many microbes of so many different kinds is what keeps you healthy most of the time.”
Dr. Ruebush deplores the current fetish for the hundreds of antibacterial products that convey a false sense of security and may actually foster the development of antibiotic-resistant, disease-causing bacteria. Plain soap and water are all that are needed to become clean, she noted.
“I certainly recommend washing your hands after using the bathroom, before eating, after changing a diaper, before and after handling food,” and whenever they’re visibly soiled, she wrote. When no running water is available and cleaning hands is essential, she suggests an alcohol-based hand sanitizer.
Dr. Weinstock goes even further. “Children should be allowed to go barefoot in the dirt, play in the dirt, and not have to wash their hands when they come in to eat,” he said. He and Dr. Elliott pointed out that children who grow up on farms and are frequently exposed to worms and other organisms from farm animals are much less likely to develop allergies and autoimmune diseases.
Also helpful, he said, is to “let kids have two dogs and a cat,” which will expose them to intestinal worms that can promote a healthy immune system.
Friday, January 23, 2009
How Do Hospitals Get Paid? A Primer
January 23, 2009, 6:40 am
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economics professor at Princeton. For previous posts in his series on why the United States spends so much on health care, click here.
Few Americans probably have any inkling of how their neighborhood hospital prices the myriad of distinct services rendered patients. I doubt many patients can understand the long hospital bills that feature exotic items such as “cath porta cath perit” or “OP6-central line reposit,” and so on. Even fewer still likely understand why a Tylenol pill or a rubber glove can carry the humongous price tags hospitals put on them.
Americans can be forgiven their ignorance on this issue because, as I put it in a recent paper on the subject, the pricing of hospital services is best described as “Chaos Behind a Veil of Secrecy.”
For starters, a hospital is paid by several quite distinct methods, depending on who is paying.
The federal Medicare program for the elderly typically pays hospitals a flat fee per hospital case, with a different per-case price for each of close to 600 distinct diagnostically related cases (D.R.G.’s) — such as a hip replacement without complications or one with complications, and so on.
These payments originally were set by Medicare in 1983 to reflect the cost then of producing each D.R.G. case. They have been updated annually and periodically recalibrated by the federal government, with the advice of Congress’s Medicare Payment Advisory Commission, a permanent body of private stakeholders with its own research staff. Through lobbying and other informal political channels the hospital industry can, of course, influence these administered prices as well. Over time, the attempt has been to keep these rates close to the average cost of providing the services per case, although many hospitals claim that often the case payments they receive are below their own full costs.
From the federal-state Medicaid program for the poor, blind and disabled, hospitals receive either (1) case-based payments (D.R.G.’s) or (2) a set amount of dollars per day of inpatient stay (per-diem payments) or (3) fees for individual services and supplies (fee-for-service or F.F.S. payments). The levels of these payments are set unilaterally by the state governments. In many states these payments are much lower than the full cost of providing the services.
Private insurers pay hospitals predominantly on the basis of per-diems or fee-for-service schedules. On average these payments exceed the hospital’s cost of providing the underlying services. The profits built into these payments cover the losses hospitals book on serving Medicare and Medicaid patients, who are billed high prices but often do not pay their bills in full. Private insurers also feed the net profits that most for-profit and not-for-profit hospitals book.
The per-diems or myriad fees that private insurers pay hospitals are negotiated annually between each hospital and each insurance carrier. A given hospital may thus negotiate one by one with several dozen or even several hundred insurers.
Readers may wonder how the many fees that hospitals receive under the fee-for-service method are negotiated separately with each hospital. Generally, the fees are not negotiated individually, but as across-the-board discounts off a giant schedule of list prices that each hospital maintains — like list prices at car dealers that no one actually pays. These schedules of list prices are known as the hospital’s “charge master.” (For an illustration, see this list of prices for some 7,500 items charged by Dameron Hospital in California.) For uninsured patients the discount is negotiated by the hospital on a patient-by-patient basis, with appeal to the patient’s ability to pay.
Each hospital has its own charge master and updates it periodically by its own unique process. Consequently, across hospitals in a given state, the list price for a particular item – e.g., a normal chest X-ray — can vary tenfold or more. In most states — California being one exception — hospitals are not required to make these charge masters public.
Over all, then, annually establishing the prices that a given insurer will pay a particular hospital and the prices charged the uninsured is an enormously cumbersome and highly labor-intensive process not used by any other health system in the industrialized world. It adds a significant component to the high administrative cost that is unique to the American health system.
One interesting aspect of this process is the wide variation in how much a basic medical service costs at different hospitals — a variation that does not appear to be tied to quality.
Tables 6.3 to 6.5 below exhibit ranges or averages of the total payments that two private health insurers make to hospitals in their state for standard medical cases. The data in the table should be understood as the total payments — per diems or fee-for-service — per standard case. I had asked for these data in my role as the chairman of the New Jersey Commission for Rationalizing Health Care Resources in 2007. The tables below are taken directly from the commission’s final report.
Source: New Jersey Commission for Rationalizing Health Care Resources
Source: New Jersey Commission for Rationalizing Health Care Resources
Source: New Jersey Commission for Rationalizing Health Care Resources
No one really understands the determinants of the wide variations in prices paid hospitals by a given insurer for basically the same medical episode. Presumably these variances reflect the relative bargaining strength of the two parties in each instance. Large insurance companies with relatively more market power vis-a-vis doctors and hospitals usually pay lower prices for given services than do smaller insurers with less market power. And traditionally, the uninsured, lacking any market power, have been charged the highest prices (i.e., granted the lowest discounts off the charge master), although in recent years more and more hospitals have switched over to a means-tested schedule of discounts off the charge master.
Critics of the federal Medicare program routinely call Medicare a “dumb” price setter. Perhaps it is. But it stretches one’s cerebral processes to conclude that the varied prices emerging from the cumbersome private market process described above are any smarter or more conducive to a rational, efficient health system. This does not mean, of course, that some economists and other defenders of the system would not try.
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economics professor at Princeton. For previous posts in his series on why the United States spends so much on health care, click here.
Few Americans probably have any inkling of how their neighborhood hospital prices the myriad of distinct services rendered patients. I doubt many patients can understand the long hospital bills that feature exotic items such as “cath porta cath perit” or “OP6-central line reposit,” and so on. Even fewer still likely understand why a Tylenol pill or a rubber glove can carry the humongous price tags hospitals put on them.
Americans can be forgiven their ignorance on this issue because, as I put it in a recent paper on the subject, the pricing of hospital services is best described as “Chaos Behind a Veil of Secrecy.”
For starters, a hospital is paid by several quite distinct methods, depending on who is paying.
The federal Medicare program for the elderly typically pays hospitals a flat fee per hospital case, with a different per-case price for each of close to 600 distinct diagnostically related cases (D.R.G.’s) — such as a hip replacement without complications or one with complications, and so on.
These payments originally were set by Medicare in 1983 to reflect the cost then of producing each D.R.G. case. They have been updated annually and periodically recalibrated by the federal government, with the advice of Congress’s Medicare Payment Advisory Commission, a permanent body of private stakeholders with its own research staff. Through lobbying and other informal political channels the hospital industry can, of course, influence these administered prices as well. Over time, the attempt has been to keep these rates close to the average cost of providing the services per case, although many hospitals claim that often the case payments they receive are below their own full costs.
From the federal-state Medicaid program for the poor, blind and disabled, hospitals receive either (1) case-based payments (D.R.G.’s) or (2) a set amount of dollars per day of inpatient stay (per-diem payments) or (3) fees for individual services and supplies (fee-for-service or F.F.S. payments). The levels of these payments are set unilaterally by the state governments. In many states these payments are much lower than the full cost of providing the services.
Private insurers pay hospitals predominantly on the basis of per-diems or fee-for-service schedules. On average these payments exceed the hospital’s cost of providing the underlying services. The profits built into these payments cover the losses hospitals book on serving Medicare and Medicaid patients, who are billed high prices but often do not pay their bills in full. Private insurers also feed the net profits that most for-profit and not-for-profit hospitals book.
The per-diems or myriad fees that private insurers pay hospitals are negotiated annually between each hospital and each insurance carrier. A given hospital may thus negotiate one by one with several dozen or even several hundred insurers.
Readers may wonder how the many fees that hospitals receive under the fee-for-service method are negotiated separately with each hospital. Generally, the fees are not negotiated individually, but as across-the-board discounts off a giant schedule of list prices that each hospital maintains — like list prices at car dealers that no one actually pays. These schedules of list prices are known as the hospital’s “charge master.” (For an illustration, see this list of prices for some 7,500 items charged by Dameron Hospital in California.) For uninsured patients the discount is negotiated by the hospital on a patient-by-patient basis, with appeal to the patient’s ability to pay.
Each hospital has its own charge master and updates it periodically by its own unique process. Consequently, across hospitals in a given state, the list price for a particular item – e.g., a normal chest X-ray — can vary tenfold or more. In most states — California being one exception — hospitals are not required to make these charge masters public.
Over all, then, annually establishing the prices that a given insurer will pay a particular hospital and the prices charged the uninsured is an enormously cumbersome and highly labor-intensive process not used by any other health system in the industrialized world. It adds a significant component to the high administrative cost that is unique to the American health system.
One interesting aspect of this process is the wide variation in how much a basic medical service costs at different hospitals — a variation that does not appear to be tied to quality.
Tables 6.3 to 6.5 below exhibit ranges or averages of the total payments that two private health insurers make to hospitals in their state for standard medical cases. The data in the table should be understood as the total payments — per diems or fee-for-service — per standard case. I had asked for these data in my role as the chairman of the New Jersey Commission for Rationalizing Health Care Resources in 2007. The tables below are taken directly from the commission’s final report.
Source: New Jersey Commission for Rationalizing Health Care Resources
Source: New Jersey Commission for Rationalizing Health Care Resources
Source: New Jersey Commission for Rationalizing Health Care Resources
No one really understands the determinants of the wide variations in prices paid hospitals by a given insurer for basically the same medical episode. Presumably these variances reflect the relative bargaining strength of the two parties in each instance. Large insurance companies with relatively more market power vis-a-vis doctors and hospitals usually pay lower prices for given services than do smaller insurers with less market power. And traditionally, the uninsured, lacking any market power, have been charged the highest prices (i.e., granted the lowest discounts off the charge master), although in recent years more and more hospitals have switched over to a means-tested schedule of discounts off the charge master.
Critics of the federal Medicare program routinely call Medicare a “dumb” price setter. Perhaps it is. But it stretches one’s cerebral processes to conclude that the varied prices emerging from the cumbersome private market process described above are any smarter or more conducive to a rational, efficient health system. This does not mean, of course, that some economists and other defenders of the system would not try.
U.S. Health Care Costs Part VII: Reining in Doctors Who Cost Too Much
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here, here and here.
Last week I wrote about the inexplicably high variation in per-capita health spending across the United States. The rich and highly heterogeneous reader responses have been illuminating and, in some cases, disturbing.
The ideal health systems recommended by readers ranged from government-run, single-payer systems to completely free-market systems in which individuals are responsible for their own health care. Both approaches, of course, ration health care — the first based on the capacity of the existing health care system, and the second based on individual patients’ ability to pay. A judgment of which system is better depends strictly on one’s moral values, not on economics.
I was surprised, though, that so few readers suggested that America’s health care spending issues might have something to do with our fee-for-service payment system.
Studies have shown that physicians are not impervious to the financial incentives inherent in fee-for-service payments. For example, on average, physicians who have a direct financial interest in the use of imaging services, like CAT scans or M.R.I. scans, recommend far more such services for their patients than do physicians without such financial interest (see this and this).
In recognition of the conflict of interest inherent in fee-for-service payment, there is now a worldwide movement to replace the system with so-called “evidence-based case reimbursement”. Under this approach, one single payment would cover all of the supplies and services that are needed, under best, evidence-based clinical practices, to respond adequately to well-defined medical conditions.
Not all health care, of course, can be categorized into neat, episodic bundles for this purpose. For chronic conditions, for example, payment may shift from fee-for-service to annual or monthly fees per patient, and care for such patients might be organized by clinically integrated health systems or by managed care companies procuring health care from different systems on an integrated basis. And for some patients with very complicated conditions, fee-for-service would still persist. One would think, however, that a move toward these alternative payment systems would not only reduce the geographic variations in per-capita health spending, but help control the annual growth of health spending over all.
Aside from payment reform, modern electronic health-information techniques can make doctors and hospitals more publicly accountable for their use of resources through greater transparency. Greater transparency in this realm is the sine qua non of a more cost-effective health system.
For example, it is technically feasible to capture electronically every supply and service requisitioned by every doctor in a hospital for every patient, by type of supply or service ordered. It is also feasible to electronically capture detailed information on the health status of every patient admitted to a hospital.
Combined, these two databases can be reorganized to produce cost-effectiveness profiles for every physician affiliated with a hospital, adjusted for the health status of their patients (in technical jargon, “risk adjusted”). Equipped with such risk-adjusted profiles, hospital administrators could periodically gather all affiliated physicians performing a particular procedure — e.g., coronary artery bypass grafts or knee replacements — into one room and ask those physicians who on average trigger high (risk-adjusted) costs for such procedures to justify these higher costs to their colleagues with lower costs.
The New Jersey Governor’s Commission on the Rationalization of Health Care Resources recommended that the state’s government help finance such hospital-based information systems and make them mandatory at all hospitals in the state. Each hospital administrator would then be required to certify that the physicians affiliated with the hospital have reviewed and discussed these cost profiles at least once a year. For hospitals seeking assistance from the state, these physician cost-effectiveness profiles should be accessible to the governor’s office as a condition for such assistance.
Short of revamping our entire health system, payment reform and more widespread use of electronic information systems most probably could drive even our existing system toward greater cost-effectiveness of care and, most likely, more moderate growth in health spending. There is every reason to believe that the Obama administration will pursue these avenues, as would have his rivals.
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here, here and here.
Last week I wrote about the inexplicably high variation in per-capita health spending across the United States. The rich and highly heterogeneous reader responses have been illuminating and, in some cases, disturbing.
The ideal health systems recommended by readers ranged from government-run, single-payer systems to completely free-market systems in which individuals are responsible for their own health care. Both approaches, of course, ration health care — the first based on the capacity of the existing health care system, and the second based on individual patients’ ability to pay. A judgment of which system is better depends strictly on one’s moral values, not on economics.
I was surprised, though, that so few readers suggested that America’s health care spending issues might have something to do with our fee-for-service payment system.
Studies have shown that physicians are not impervious to the financial incentives inherent in fee-for-service payments. For example, on average, physicians who have a direct financial interest in the use of imaging services, like CAT scans or M.R.I. scans, recommend far more such services for their patients than do physicians without such financial interest (see this and this).
In recognition of the conflict of interest inherent in fee-for-service payment, there is now a worldwide movement to replace the system with so-called “evidence-based case reimbursement”. Under this approach, one single payment would cover all of the supplies and services that are needed, under best, evidence-based clinical practices, to respond adequately to well-defined medical conditions.
Not all health care, of course, can be categorized into neat, episodic bundles for this purpose. For chronic conditions, for example, payment may shift from fee-for-service to annual or monthly fees per patient, and care for such patients might be organized by clinically integrated health systems or by managed care companies procuring health care from different systems on an integrated basis. And for some patients with very complicated conditions, fee-for-service would still persist. One would think, however, that a move toward these alternative payment systems would not only reduce the geographic variations in per-capita health spending, but help control the annual growth of health spending over all.
Aside from payment reform, modern electronic health-information techniques can make doctors and hospitals more publicly accountable for their use of resources through greater transparency. Greater transparency in this realm is the sine qua non of a more cost-effective health system.
For example, it is technically feasible to capture electronically every supply and service requisitioned by every doctor in a hospital for every patient, by type of supply or service ordered. It is also feasible to electronically capture detailed information on the health status of every patient admitted to a hospital.
Combined, these two databases can be reorganized to produce cost-effectiveness profiles for every physician affiliated with a hospital, adjusted for the health status of their patients (in technical jargon, “risk adjusted”). Equipped with such risk-adjusted profiles, hospital administrators could periodically gather all affiliated physicians performing a particular procedure — e.g., coronary artery bypass grafts or knee replacements — into one room and ask those physicians who on average trigger high (risk-adjusted) costs for such procedures to justify these higher costs to their colleagues with lower costs.
The New Jersey Governor’s Commission on the Rationalization of Health Care Resources recommended that the state’s government help finance such hospital-based information systems and make them mandatory at all hospitals in the state. Each hospital administrator would then be required to certify that the physicians affiliated with the hospital have reviewed and discussed these cost profiles at least once a year. For hospitals seeking assistance from the state, these physician cost-effectiveness profiles should be accessible to the governor’s office as a condition for such assistance.
Short of revamping our entire health system, payment reform and more widespread use of electronic information systems most probably could drive even our existing system toward greater cost-effectiveness of care and, most likely, more moderate growth in health spending. There is every reason to believe that the Obama administration will pursue these avenues, as would have his rivals.
U.S. Health Care Costs Part VI: At What Price Physician Autonomy?
December 26, 2008, 10:07 am
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here and here.
After a lengthy discourse on health policy with a physician, I asked him to describe the ideal health system from a physician’s perspective. “Everyone in society should have access to needed health care,” he responded. “Only the physician and the patient should decide how to respond to a given medical condition. And someone should reimburse providers of health care at reasonable rates.”
Leave aside the fact that providers of health care are “paid” for their services, not “reimbursed,” the latter method always breeding bad managerial habits. Leave aside also that the definition of “needed” health care is highly elastic. Focus instead on the core of the ideal: complete clinical autonomy for physicians and their patients to throw whatever resources they wish at given medical conditions, usually at someone else’s expense, with little or no accountability for their preferred treatments’ quality or success.
Most physicians, and I would suspect most of their patients, probably subscribe to this ideal. Alas, a mounting body of research leads experts to doubt that physician autonomy actually serves society well and that it will be affordable much longer.
One strand of this research is typified by a landmark study conducted by Elizabeth A. McGlynn and her research associates at the Rand Corporation. The researchers found that, on average, American patients receive the recommended treatment for their condition only slightly more than 50 percent of the time. There are numerous other studies of this genre.
Another strand of research can be found in the famous and equally widely quoted Dartmouth Atlas of Health Care published by John E. Wennberg and his research associates at the Dartmouth Medical School. These researchers have for two decades now alerted Congress, the medical profession and private insurers to huge geographic variations in per-capita health spending that do not seem to be related to commensurate differences in disease rates, the quality of health care processes, clinical outcomes or patient satisfaction.
Table 6.1 below, taken from the Final Report of the New Jersey Commission on Rationalizing Health Care Resources, illustrates these inexplicable geographic variations in per-capita spending. As the chair of that commission, I had asked Dr. Wennberg to develop for the commission data on Medicare spending per beneficiary in New Jersey’s various hospital market areas.
Shown in the table are the average payments for inpatient care that Medicare made per beneficiary residing in a selected number of hospital-market areas during these beneficiaries’ last two years of life. The averages have been statistically adjusted to account for differences in the gender and age of patients who come to different hospitals and also for differences in the fees Medicare pays hospitals. (Although in principle Medicare uses one uniform fee schedule nationwide, some regional adjustments are made to fees to account for local differences in labor and other practice costs). It follows that the data in the table reflect differences in the use of real resources (hospital days, procedures per hospital day, etc.) and not price differences.
The numbers in the chart are all being compared to how much Medicare reimburses hospitals nationwide, on average, for taking care of a patient in the last two years of his or her life. In technical terms, this means that if a number in the table is equal to 1, then the actual spending per beneficiary, or the actual use of hospital days, etc., in the corresponding New Jersey market area is exactly equal to the national average.
For example, the number 3.21 for the St. Michaels Medical Center hospital market area in the table means that, during their last two years of life, Medicare beneficiaries in this area were 3.21 more costly to the taxpayer times for inpatient care than were similar patients nationwide. These patients received 2.34 times more hospital inpatient days than the national average, and each hospital day they received cost 1.37 times as much as the comparable national average. By contrast, for patients in the Atlantic Medical Center market area, the statistics are very close to the national average, because the numbers for that area are all close to 1.
The insight one gains from the table is that Medicare spending per beneficiary varied by a factor of three across New Jersey, depending on the practice style preferred by the physicians caring for these patients. As the right-most column in the table suggest, there does not appear to be any systematic relationship between Medicare spending and Medicare’s hospital-specific quality index.
Hospital executives, confronted with these numbers, have explained that they have little control over the utilization of health-care resources within their hospitals, as that is the prerogative of the private, usually self-employed physicians who have privileges at these hospitals and can look upon the latter as their free workshops. Furthermore, these executives would be loath to reproach the physicians responsible for using the most Medicare dollars, lest those physicians shift their patients to rival hospitals. Most health-care experts accept these explanations.
Dr. Wennberg and his associates at Dartmouth Medical have published similar data for California and for the nation as a whole. In their most recent publication, they show that these enormous variations in per-capita health spending are confined not only to the traditional, government-run, fee-for-service part of Medicare, but are apparent also for Medicare beneficiaries served by the private “Medicare Advantage” plans as well as among the commercially insured patients served by these private plans. They are a feature of all medical practice in America, regardless of who pays for the care.
The wonder is that neither Congress, nor the medical profession, nor private health insurers has so far felt obligated to come to grips with these enormous variations in health spending nor even to evince any curiosity about them.
According to the Dartmouth researchers, if physicians with relatively higher cost preferred practice styles could be induced to embrace the preferred practice styles of their equally effective but lower-cost colleagues, overall per-capita Medicare spending probably could be reduced by at least 30 percent without harming patients, and similarly for commercially insured younger Americans. How can a nation that routinely wails over its high cost of health care ignore such important research?
In a future post to this blog, I shall explore what might possibly be done to address this issue. In the meantime, it would be fascinating to learn from their comments what readers would do, were they American health-care czars.
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here and here.
After a lengthy discourse on health policy with a physician, I asked him to describe the ideal health system from a physician’s perspective. “Everyone in society should have access to needed health care,” he responded. “Only the physician and the patient should decide how to respond to a given medical condition. And someone should reimburse providers of health care at reasonable rates.”
Leave aside the fact that providers of health care are “paid” for their services, not “reimbursed,” the latter method always breeding bad managerial habits. Leave aside also that the definition of “needed” health care is highly elastic. Focus instead on the core of the ideal: complete clinical autonomy for physicians and their patients to throw whatever resources they wish at given medical conditions, usually at someone else’s expense, with little or no accountability for their preferred treatments’ quality or success.
Most physicians, and I would suspect most of their patients, probably subscribe to this ideal. Alas, a mounting body of research leads experts to doubt that physician autonomy actually serves society well and that it will be affordable much longer.
One strand of this research is typified by a landmark study conducted by Elizabeth A. McGlynn and her research associates at the Rand Corporation. The researchers found that, on average, American patients receive the recommended treatment for their condition only slightly more than 50 percent of the time. There are numerous other studies of this genre.
Another strand of research can be found in the famous and equally widely quoted Dartmouth Atlas of Health Care published by John E. Wennberg and his research associates at the Dartmouth Medical School. These researchers have for two decades now alerted Congress, the medical profession and private insurers to huge geographic variations in per-capita health spending that do not seem to be related to commensurate differences in disease rates, the quality of health care processes, clinical outcomes or patient satisfaction.
Table 6.1 below, taken from the Final Report of the New Jersey Commission on Rationalizing Health Care Resources, illustrates these inexplicable geographic variations in per-capita spending. As the chair of that commission, I had asked Dr. Wennberg to develop for the commission data on Medicare spending per beneficiary in New Jersey’s various hospital market areas.
Shown in the table are the average payments for inpatient care that Medicare made per beneficiary residing in a selected number of hospital-market areas during these beneficiaries’ last two years of life. The averages have been statistically adjusted to account for differences in the gender and age of patients who come to different hospitals and also for differences in the fees Medicare pays hospitals. (Although in principle Medicare uses one uniform fee schedule nationwide, some regional adjustments are made to fees to account for local differences in labor and other practice costs). It follows that the data in the table reflect differences in the use of real resources (hospital days, procedures per hospital day, etc.) and not price differences.
The numbers in the chart are all being compared to how much Medicare reimburses hospitals nationwide, on average, for taking care of a patient in the last two years of his or her life. In technical terms, this means that if a number in the table is equal to 1, then the actual spending per beneficiary, or the actual use of hospital days, etc., in the corresponding New Jersey market area is exactly equal to the national average.
For example, the number 3.21 for the St. Michaels Medical Center hospital market area in the table means that, during their last two years of life, Medicare beneficiaries in this area were 3.21 more costly to the taxpayer times for inpatient care than were similar patients nationwide. These patients received 2.34 times more hospital inpatient days than the national average, and each hospital day they received cost 1.37 times as much as the comparable national average. By contrast, for patients in the Atlantic Medical Center market area, the statistics are very close to the national average, because the numbers for that area are all close to 1.
The insight one gains from the table is that Medicare spending per beneficiary varied by a factor of three across New Jersey, depending on the practice style preferred by the physicians caring for these patients. As the right-most column in the table suggest, there does not appear to be any systematic relationship between Medicare spending and Medicare’s hospital-specific quality index.
Hospital executives, confronted with these numbers, have explained that they have little control over the utilization of health-care resources within their hospitals, as that is the prerogative of the private, usually self-employed physicians who have privileges at these hospitals and can look upon the latter as their free workshops. Furthermore, these executives would be loath to reproach the physicians responsible for using the most Medicare dollars, lest those physicians shift their patients to rival hospitals. Most health-care experts accept these explanations.
Dr. Wennberg and his associates at Dartmouth Medical have published similar data for California and for the nation as a whole. In their most recent publication, they show that these enormous variations in per-capita health spending are confined not only to the traditional, government-run, fee-for-service part of Medicare, but are apparent also for Medicare beneficiaries served by the private “Medicare Advantage” plans as well as among the commercially insured patients served by these private plans. They are a feature of all medical practice in America, regardless of who pays for the care.
The wonder is that neither Congress, nor the medical profession, nor private health insurers has so far felt obligated to come to grips with these enormous variations in health spending nor even to evince any curiosity about them.
According to the Dartmouth researchers, if physicians with relatively higher cost preferred practice styles could be induced to embrace the preferred practice styles of their equally effective but lower-cost colleagues, overall per-capita Medicare spending probably could be reduced by at least 30 percent without harming patients, and similarly for commercially insured younger Americans. How can a nation that routinely wails over its high cost of health care ignore such important research?
In a future post to this blog, I shall explore what might possibly be done to address this issue. In the meantime, it would be fascinating to learn from their comments what readers would do, were they American health-care czars.
U.S. Health Care Costs, Part V: Can Americans Afford Medicare?
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here and here.
It is now generally believed that the federal Medicare program for America’s elderly is “unsustainable” and must be “restructured.” This somber assessment is part of the more general cri de coeur so wondrously phrased some years ago in the title of the Brookings Institution’s monograph “Can America Afford to Grow Old?”
What if we couldn’t? What would we do – push the elderly into the ocean on an ice floe?
Of course America can afford to grow old! We can more easily afford it than most other industrialized nations.
The percentage of the American population age 65 or over is 12.4 now and is projected to rise to about 21 by 2050. Only 7 percent of China’s population is 65 or over now, but that figure will shoot up rapidly to over 22 percent by 2050. And in a number of other industrialized countries — notably in Japan, Germany, Italy and Sweden — the elderly already represent close to 20 percent of the population, a level the United States will not reach until about 2040. Yet the world has not come to an end in these older countries.
It’s hard to say what fraction of America’s gross domestic product future generations should allocate to people too old (or too young) to work, and how much should remain with those who have produced that G.D.P. This is a matter to be resolved by those future generations.
They must decide how well the elderly in their midst should be housed, fed and cared for when sick. Our influence over that allocation is minimal, because future generations can always override our decisions while we cannot override theirs. The best we can do today is to put in place public policies that can help G.D.P. grow now and in the future, to ease the pain of sharing. We could also influence somewhat the age structure of future populations through current and future policies on immigration, although there are limits to that approach, because immigrants, too, grow old.
Fortunately, as is shown in the graphical display below, future generations will most likely have the benefit of G.D.P. growth on their side, which should make it easier for them to house, feed and care for larger fractions of elderly citizens.
Current G.D.P. per capita in the United States is about $46,500 (tables B-2 and B-34 here), of which Medicare absorbs slightly over 3 percent, leaving about $45,000 of G.D.P. per capita for other things.
Suppose between now and, say, 2050, inflation-adjusted G.D.P. per capita in the United States grows at an annual compound rate of only 1.5 percent per year, which is conservatively below the roughly 2 percent long-run annual growth rate of real G.D.P. per capita over the past several decades. Even at this low growth rate, inflation-adjusted G.D.P. per capita would grow from $46,500 now to about $87,000 by 2050.
According to the Social Security Trustees’ 2008 Report on the Status of the Social Security and Medicare Programs (Chart B), Medicare will absorb about 8.4 percent of G.D.P. by 2050 if it is not restructured.
But even after that 8.4 percent haircut for Medicare in 2050, there would still be close to $80,000 inflation-adjusted G.D.P. per capita left over for other things in that year, which is still 78 percent more than the non-Medicare G.D.P. per capita that we have today.
Source: Uwe E. Reinhardt.
So what do we mean when we lament that Medicare will not be “affordable” in the future? Do we assume that G.D.P. will be stagnant for the next 40 years?
Those who make such statements, of course, may not even think about real claims on real G.D.P. Instead they may have in mind two quite different propositions.
First, they may argue that even if Medicare were eminently affordable from a purely macroeconomic perspective, its current structure of mainly public financing may not be politically sustainable. There is no question that to allocate as much as 8.4 percent of 2050 G.D.P. to Medicare under its current structure would require sizable tax increases. But social values and preferences can change. Future cohorts of voting retirees and their children in the United States may well countenance the higher levels of taxation already long accepted in other industrialized nations, in return for greater personal financial security.
An alternative proposition may be that, even if (1) sustaining Medicare in its current structure were eminently affordable from a macroeconomic perspective, and (2) it were politically feasible, we still shouldn’t sustain Medicare in its present form because the program wastes real and financial resources.
There is something to the second proposition, as will be explained in detail in my next post to this blog.
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here and here.
It is now generally believed that the federal Medicare program for America’s elderly is “unsustainable” and must be “restructured.” This somber assessment is part of the more general cri de coeur so wondrously phrased some years ago in the title of the Brookings Institution’s monograph “Can America Afford to Grow Old?”
What if we couldn’t? What would we do – push the elderly into the ocean on an ice floe?
Of course America can afford to grow old! We can more easily afford it than most other industrialized nations.
The percentage of the American population age 65 or over is 12.4 now and is projected to rise to about 21 by 2050. Only 7 percent of China’s population is 65 or over now, but that figure will shoot up rapidly to over 22 percent by 2050. And in a number of other industrialized countries — notably in Japan, Germany, Italy and Sweden — the elderly already represent close to 20 percent of the population, a level the United States will not reach until about 2040. Yet the world has not come to an end in these older countries.
It’s hard to say what fraction of America’s gross domestic product future generations should allocate to people too old (or too young) to work, and how much should remain with those who have produced that G.D.P. This is a matter to be resolved by those future generations.
They must decide how well the elderly in their midst should be housed, fed and cared for when sick. Our influence over that allocation is minimal, because future generations can always override our decisions while we cannot override theirs. The best we can do today is to put in place public policies that can help G.D.P. grow now and in the future, to ease the pain of sharing. We could also influence somewhat the age structure of future populations through current and future policies on immigration, although there are limits to that approach, because immigrants, too, grow old.
Fortunately, as is shown in the graphical display below, future generations will most likely have the benefit of G.D.P. growth on their side, which should make it easier for them to house, feed and care for larger fractions of elderly citizens.
Current G.D.P. per capita in the United States is about $46,500 (tables B-2 and B-34 here), of which Medicare absorbs slightly over 3 percent, leaving about $45,000 of G.D.P. per capita for other things.
Suppose between now and, say, 2050, inflation-adjusted G.D.P. per capita in the United States grows at an annual compound rate of only 1.5 percent per year, which is conservatively below the roughly 2 percent long-run annual growth rate of real G.D.P. per capita over the past several decades. Even at this low growth rate, inflation-adjusted G.D.P. per capita would grow from $46,500 now to about $87,000 by 2050.
According to the Social Security Trustees’ 2008 Report on the Status of the Social Security and Medicare Programs (Chart B), Medicare will absorb about 8.4 percent of G.D.P. by 2050 if it is not restructured.
But even after that 8.4 percent haircut for Medicare in 2050, there would still be close to $80,000 inflation-adjusted G.D.P. per capita left over for other things in that year, which is still 78 percent more than the non-Medicare G.D.P. per capita that we have today.
Source: Uwe E. Reinhardt.
So what do we mean when we lament that Medicare will not be “affordable” in the future? Do we assume that G.D.P. will be stagnant for the next 40 years?
Those who make such statements, of course, may not even think about real claims on real G.D.P. Instead they may have in mind two quite different propositions.
First, they may argue that even if Medicare were eminently affordable from a purely macroeconomic perspective, its current structure of mainly public financing may not be politically sustainable. There is no question that to allocate as much as 8.4 percent of 2050 G.D.P. to Medicare under its current structure would require sizable tax increases. But social values and preferences can change. Future cohorts of voting retirees and their children in the United States may well countenance the higher levels of taxation already long accepted in other industrialized nations, in return for greater personal financial security.
An alternative proposition may be that, even if (1) sustaining Medicare in its current structure were eminently affordable from a macroeconomic perspective, and (2) it were politically feasible, we still shouldn’t sustain Medicare in its present form because the program wastes real and financial resources.
There is something to the second proposition, as will be explained in detail in my next post to this blog.
Why Does U.S. Health Care Cost So Much? (Part IV: A Primer on Medicare)
December 12, 2008, 6:30 am
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here and here.
Medicare, the federal health-insurance program for America’s elderly, plays a major and highly controversial role in our health-care system. To many Americans it is a blessing. Others view it as a source of all that’s wrong with American health care. I propose to explore these views in this and the next two posts to this blog.
Congress established Medicare in 1965, when close to 40 percent of America’s elderly lived at or below the federal poverty line. They simply could not afford the ever more sophisticated and expensive health care then starting to come on line.
The program now covers 45 million Americans 65 or older, as well as younger people with permanent disabilities, among them patients afflicted with End Stage Renal Disease. About half of Medicare beneficiaries live at or below 200 percent of the federal poverty line (i.e., $20,800 annual income for a single person and $28,000 for a couple). Over a third of the beneficiaries are afflicted with three or more chronic conditions.
In 2009, Medicare is expected to cost the federal government about $480 billion. That represents over a fifth of total national health spending on personal health care, 13 percent of the federal budget and close to 3.5 percent of the country’s gross domestic product. These outlays are financed with a combination of payroll taxes (41 percent), general tax revenues (39 percent), premiums paid by the elderly (12 percent) and sundry other sources, including interest earned on a trust fund established for the program.
Because Medicare’s benefit package traditionally has been less generous than traditional employment-based private insurance for younger Americans –- it has covered prescription drugs only since 2006 — many beneficiaries have sought supplemental, wrap-around coverage from their former employers (about 33 percent) or from a purchase of a private Medigap policy (about 20 percent). The federal-state Medicaid program for the poor provides such gap coverage for some 7 million (or 15.5 percent) Medicare beneficiaries, called “dual eligibles.”
Even with such supplemental coverage, however, out-of-pocket cost-sharing at the time health care is received has always been high relative to employment-based private insurance for younger Americans. In 2005, the median fraction of income Medicare beneficiaries spent out of pocket for their care was 16.1 percent. For the 11 percent of beneficiaries without supplemental coverage, out-of-pocket spending can absorb 30 percent or more of their income.
Medicare was originally established as a single-payer, government-run, fee-for-service plan whose claims by patients and health care providers were administered, for a modest fee, by a select group of private insurance plans called Medicare Intermediaries -– typically Blue Cross plans. This arrangement is now known as “Traditional FFS Medicare.”
Starting in the 1970s, however, Medicare beneficiaries have had the option of enrolling in a variety of health plans offered by private insurers. Starting with the Medicare Modernization Act passed in December 2003, which offered beneficiaries drug coverage for the first time, these private insurance options have been called “Medicare Advantage” plans. About 23 percent of Medicare beneficiaries have chosen this option.
Driven by an ideological preference for private over government-run health insurance, the Republican Congress in 2003 made taxpayers effectively pay these private plans an average of 13 percent more per Medicare beneficiary than these beneficiaries would have cost taxpayers under the government-run program. Consequently, the private plans can offer beneficiaries superior benefits, which has caused enrollment in them to double from 5.3 million to 10.1 million between 2003 and 2008. Because it is hard to justify this extra public subsidy to the private plans on the basis of health policy, however, it has been highly controversial among health policy experts and is likely to be eliminated by the new Congress in the next few years.
Although often decried by its critics as “socialized medicine,” Medicare remains a highly popular health-insurance product among the elderly, who rate the quality of care they receive under it higher than younger, privately insured Americans rate their health care (see, for example, this and also this, Charts 4:1 to 4:3).
This sentiment is not surprising, because, from both the patient’s and the provider’s perspective, claims processing under Medicare is relatively simple in comparison with the complexity of private health insurance, although Medicare is much more administratively complex than are similar government-run, single-payer health insurance systems in other countries (e.g., Taiwan or Canada).
Furthermore, in surveys of Americans 50 and older, respondents expressed greater trust in Medicare as a source of health insurance, possibly still remembering the late 1990s, when many private plans terminated their coverage of Medicare patients.
In the next post, I shall assess the often-made claim that Medicare is not much longer “sustainable.” Thereafter I shall explore whether Medicare in its current form should be sustained, even if it were affordable in that form. In the meantime, readers who wish more detail on the program than could be offered here may wish to consult the excellent primer on Medicare found at the Henry J. Kaiser Family Foundation’s Web site.
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here and here.
Medicare, the federal health-insurance program for America’s elderly, plays a major and highly controversial role in our health-care system. To many Americans it is a blessing. Others view it as a source of all that’s wrong with American health care. I propose to explore these views in this and the next two posts to this blog.
Congress established Medicare in 1965, when close to 40 percent of America’s elderly lived at or below the federal poverty line. They simply could not afford the ever more sophisticated and expensive health care then starting to come on line.
The program now covers 45 million Americans 65 or older, as well as younger people with permanent disabilities, among them patients afflicted with End Stage Renal Disease. About half of Medicare beneficiaries live at or below 200 percent of the federal poverty line (i.e., $20,800 annual income for a single person and $28,000 for a couple). Over a third of the beneficiaries are afflicted with three or more chronic conditions.
In 2009, Medicare is expected to cost the federal government about $480 billion. That represents over a fifth of total national health spending on personal health care, 13 percent of the federal budget and close to 3.5 percent of the country’s gross domestic product. These outlays are financed with a combination of payroll taxes (41 percent), general tax revenues (39 percent), premiums paid by the elderly (12 percent) and sundry other sources, including interest earned on a trust fund established for the program.
Because Medicare’s benefit package traditionally has been less generous than traditional employment-based private insurance for younger Americans –- it has covered prescription drugs only since 2006 — many beneficiaries have sought supplemental, wrap-around coverage from their former employers (about 33 percent) or from a purchase of a private Medigap policy (about 20 percent). The federal-state Medicaid program for the poor provides such gap coverage for some 7 million (or 15.5 percent) Medicare beneficiaries, called “dual eligibles.”
Even with such supplemental coverage, however, out-of-pocket cost-sharing at the time health care is received has always been high relative to employment-based private insurance for younger Americans. In 2005, the median fraction of income Medicare beneficiaries spent out of pocket for their care was 16.1 percent. For the 11 percent of beneficiaries without supplemental coverage, out-of-pocket spending can absorb 30 percent or more of their income.
Medicare was originally established as a single-payer, government-run, fee-for-service plan whose claims by patients and health care providers were administered, for a modest fee, by a select group of private insurance plans called Medicare Intermediaries -– typically Blue Cross plans. This arrangement is now known as “Traditional FFS Medicare.”
Starting in the 1970s, however, Medicare beneficiaries have had the option of enrolling in a variety of health plans offered by private insurers. Starting with the Medicare Modernization Act passed in December 2003, which offered beneficiaries drug coverage for the first time, these private insurance options have been called “Medicare Advantage” plans. About 23 percent of Medicare beneficiaries have chosen this option.
Driven by an ideological preference for private over government-run health insurance, the Republican Congress in 2003 made taxpayers effectively pay these private plans an average of 13 percent more per Medicare beneficiary than these beneficiaries would have cost taxpayers under the government-run program. Consequently, the private plans can offer beneficiaries superior benefits, which has caused enrollment in them to double from 5.3 million to 10.1 million between 2003 and 2008. Because it is hard to justify this extra public subsidy to the private plans on the basis of health policy, however, it has been highly controversial among health policy experts and is likely to be eliminated by the new Congress in the next few years.
Although often decried by its critics as “socialized medicine,” Medicare remains a highly popular health-insurance product among the elderly, who rate the quality of care they receive under it higher than younger, privately insured Americans rate their health care (see, for example, this and also this, Charts 4:1 to 4:3).
This sentiment is not surprising, because, from both the patient’s and the provider’s perspective, claims processing under Medicare is relatively simple in comparison with the complexity of private health insurance, although Medicare is much more administratively complex than are similar government-run, single-payer health insurance systems in other countries (e.g., Taiwan or Canada).
Furthermore, in surveys of Americans 50 and older, respondents expressed greater trust in Medicare as a source of health insurance, possibly still remembering the late 1990s, when many private plans terminated their coverage of Medicare patients.
In the next post, I shall assess the often-made claim that Medicare is not much longer “sustainable.” Thereafter I shall explore whether Medicare in its current form should be sustained, even if it were affordable in that form. In the meantime, readers who wish more detail on the program than could be offered here may wish to consult the excellent primer on Medicare found at the Henry J. Kaiser Family Foundation’s Web site.
Why Does U.S. Health Care Cost So Much? (Part III: An Aging Population Isn’t the Reason)
By Uwe E. Reinhardt
Uwe E. Reinhardt is an economist at Princeton.
Update | Professor Reinhardt responds to commenters here.
Not a conference on health care goes by without someone’s asserting that the aging of our population is a major driver of the annual growth in health spending. It sounds intuitively appealing if one contemplates the following two graphs, which are regularly trotted out on such occasions.
Graph courtesy of Uwe Reinhardt.
Graph courtesy of Uwe Reinhardt.
The first graph depicts what is commonly described as the “Baby Boom Tsunami.” The second depicts age-specific health spending per capita in 1999, relative to the spending of Americans in the age group 35 to 44, which is set to 1. These age-specific relative spending profiles do not change much over time for a given country, and they do not much differ among industrialized nations. They show that after age 60 or so, health spending per capita rises sharply with age.
Yet, research around the world has shown that the process of the aging of the population by itself adds only a very small part – usually about half a percentage point — to the annual growth in per-capita health spending in industrialized societies, which tends to range between 5 and 8 percent, depending on the country and the period in question. The bulk of annual spending growth can be explained by overall population growth (about 1.1 percent per year), increases in the prices of health care goods and services, and the availability of ever more new, often high-cost medical products and treatments used by all age groups.
Because this proposition is so counterintuitive, readers may wish to consult two recent research papers on the topic, one penned by the present author, and the other penned by other researchers.
These papers are based on American data. Similar studies have appeared also for Canada, Australia and many other countries in the Organization for Economic Cooperation and Development. Indeed, it may surprise readers that knowing the percentage of a nation’s population that is over age 65 cannot help one explain cross-national differences in health spending per capita, as is shown in the graph further on. As the graph shows, the per-capita health spending of nations is virtually independent of the age structure of its population.
Graph courtesy of Uwe Reinhardt.
Why, then, is the aging of the population such a small driver of annual increases in health spending? The answer can be found in the last graphical display of this commentary. That graph contains the same data as the first graph in this commentary, but the vertical axis is scaled as it should be scaled: from 0 percent to 100 percent. Letting it run from 12 percent to 22 percent stretches the vertical axis and creates the image of the famous Baby Boom Tsunami. It is a form of lying with statistics.
Graph courtesy of Uwe Reinhardt.
As this graph illustrates, the aging of our population is a very gradual process and does not come even close to resembling a tsunami. It is at best a demographic ripple.
Furthermore, current population projections have the fraction of elderly in the United States population peak at around 20 percent. Along with Canada and Australia, we shall be for a very long time the youngest nation in the O.E.C.D. Only in 2025 will the American population be as “old” as many European populations are already today.
As the song goes, relative to other nations we shall be “forever young”!
Uwe E. Reinhardt is an economist at Princeton.
Update | Professor Reinhardt responds to commenters here.
Not a conference on health care goes by without someone’s asserting that the aging of our population is a major driver of the annual growth in health spending. It sounds intuitively appealing if one contemplates the following two graphs, which are regularly trotted out on such occasions.
Graph courtesy of Uwe Reinhardt.
Graph courtesy of Uwe Reinhardt.
The first graph depicts what is commonly described as the “Baby Boom Tsunami.” The second depicts age-specific health spending per capita in 1999, relative to the spending of Americans in the age group 35 to 44, which is set to 1. These age-specific relative spending profiles do not change much over time for a given country, and they do not much differ among industrialized nations. They show that after age 60 or so, health spending per capita rises sharply with age.
Yet, research around the world has shown that the process of the aging of the population by itself adds only a very small part – usually about half a percentage point — to the annual growth in per-capita health spending in industrialized societies, which tends to range between 5 and 8 percent, depending on the country and the period in question. The bulk of annual spending growth can be explained by overall population growth (about 1.1 percent per year), increases in the prices of health care goods and services, and the availability of ever more new, often high-cost medical products and treatments used by all age groups.
Because this proposition is so counterintuitive, readers may wish to consult two recent research papers on the topic, one penned by the present author, and the other penned by other researchers.
These papers are based on American data. Similar studies have appeared also for Canada, Australia and many other countries in the Organization for Economic Cooperation and Development. Indeed, it may surprise readers that knowing the percentage of a nation’s population that is over age 65 cannot help one explain cross-national differences in health spending per capita, as is shown in the graph further on. As the graph shows, the per-capita health spending of nations is virtually independent of the age structure of its population.
Graph courtesy of Uwe Reinhardt.
Why, then, is the aging of the population such a small driver of annual increases in health spending? The answer can be found in the last graphical display of this commentary. That graph contains the same data as the first graph in this commentary, but the vertical axis is scaled as it should be scaled: from 0 percent to 100 percent. Letting it run from 12 percent to 22 percent stretches the vertical axis and creates the image of the famous Baby Boom Tsunami. It is a form of lying with statistics.
Graph courtesy of Uwe Reinhardt.
As this graph illustrates, the aging of our population is a very gradual process and does not come even close to resembling a tsunami. It is at best a demographic ripple.
Furthermore, current population projections have the fraction of elderly in the United States population peak at around 20 percent. Along with Canada and Australia, we shall be for a very long time the youngest nation in the O.E.C.D. Only in 2025 will the American population be as “old” as many European populations are already today.
As the song goes, relative to other nations we shall be “forever young”!
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